Transcript of Revised for 2013 Shannon Hein RN, CPN(C). published in the Canadian Medical Association Journal in...
- Slide 1
- Revised for 2013 Shannon Hein RN, CPN(C)
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- published in the Canadian Medical Association Journal in May
2004 Found an overall incidence rate of adverse events of 7.5% Of
the almost 2.5 million annual hospital admissions; about 185 000
are associated with an adverse event close to 70 000 of these are
potentially preventable (CMAJ May 25, 2004 170:1643)
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- Of 719 Events investigated 2004-2012: Human Factors 443
Communication 388 Assessment 357 Leadership 299 Information
Management 140 Operative Care 103 Physical Environment 80 Care
Planning 76 Medication Use 70 Continuum of Care 61 (The majority of
events have multiple root causes) (The Joint Commission Sentinel
Event Data; Root Causes by Event Type 2004-2012)
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- Of 928 Events investigated 2004-2012: Leadership 770
Communication 634 Human Factors 618 Information Management 338
Operative Care 313 Assessment 311 Physical Environment 89 Patient
Rights 55 Anesthesia Care 46 Continuum of Care 36 (The majority of
events have multiple root causes) (The Joint Commission Sentinel
Event Data; Root Causes by Event Type 2004-2012)
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- Of 773 Events investigated 2004-2012: Leadership 614 Human
Factors 502 Communication 496 Operative Care 436 Assessment 195
Physical Environment 174 Information Management 127 Continuum of
Care 21 Performance Improvement 13 Care Planning 8 (The majority of
events have multiple root causes) (The Joint Commission Sentinel
Event Data; Root Causes by Event Type 2004-2012)
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- communication tool intended to be used by clinicians to improve
the safety and quality of patient care during surgical procedures
shown to reduce (>30%) the number of preventable complications /
mortality associated with surgery by ensuring critical information
is shared with all members of the surgical team (NEJM
2009;360:491-499) Now >3900 hospitals worldwide (122 countries)
more than 90% of the worlds population (WHO)
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- A Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Population Between October 2007 and September 2008,
eight hospitals in eight cities collected data on 3733 patients Pre
Safe Surgery Checklist and 3955 Post Safe Surgery Checklist The
rate of death was 0.9% before the checklist was introduced and
declined to 0.6% afterward (high income sites Toronto, Auckland,
London, Seattle) Inpatient complications occurred in 10.3% of
patients at baseline and in 7.1% after introduction of the
checklist (at high income sites) Checklist adherence was measured
and tight correlations were found between the use of the checklist
and achieving these results.
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- A modified version of the WHO Safe Surgery Checklist was
introduced to AHS in January 2010 The method of delivery has varied
from site to site, with compliance also varying Recognizing that
many staff work at multiple sites..
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- The Safe Surgery Checklist was modified and standardized to
ensure that all sites across Alberta are completing the necessary
steps After 2013, Safe Surgery Checklist becomes an Accreditation
Canada requirement The Covenant Health Safe Surgery Checklist
Policy.
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- Safe Surgery Checklist Required for all surgical interventions
All steps must be completed by the appropriate people Required to
be documented on patients health record If Briefing is not
completed, the case does not proceed Surgeon and Anesthesiologist:
must be staff or Fellow
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- The Checklist Lead ensures the completion of each section of
the Checklist. All steps in each section must be complete before
proceeding Briefing: Surgeon Time Out: Nurse Debriefing: Nurse
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- As soon as patient is in the Operating Room, before Induction
of Anesthesia Patient or family member Anesthesiologist Surgeon
Nurse All MUST be present for Briefing
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- Immediately before incision Initial instrument will be kept on
back table until Time Out is complete Anesthesiologist Surgeon
Nursing All MUST be present for Time Out
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- During Wound Closure Cavity Count must be complete
Anesthesiologist Surgeon Nursing All MUST be present for
Debriefing
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- Safe Surgery Checklist will be part of the chart Each section
(Briefing, Time Out and Debriefing) will be represented The
Checklist Lead ensures these sections are complete Each section is
then signed off on the chart
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- Where is it done? All three sections will be done in the
Operating Room. In the event that a patient has an interpreter or
cannot represent themselves, the Briefing will take place in the
Pre Operative Holding area. Why the changes? To ensure that all
hospitals across Alberta are doing the same standardized Checklist.
Is this going to slow things down? In the beginning, this may have
its growing pains. But, it has actually been proven to save time in
many situations
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- Can a Resident do the Checklist in place of the Physician? No.
The AHS and Covenant Health policies require the Surgeon and
Anesthesiologist to be either Staff or Clinical Fellow. Is this for
all surgeries? Yes What are the other hospitals doing? All
hospitals in Alberta are doing the Safe Surgery Checklist and are
required to meet all of the steps and criteria. Is this part of the
patient chart? Yes
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- Does the Checklist have to be done in an Emergency situation?
The Most Responsible Health Practitioner will use discretion in
determining which sections of the Checklist will be completed.
Documentation of this will go in the patients Health Record. What
if the patient is undergoing multiple procedures? The Surgeon or
alternative surgeon, Anesthesiologist or alternative
anesthesiologist and nurse must be present for Briefing and Time
Out for each distinct procedure. Upon completion of all procedures,
the most responsible surgeon, the anesthesiologist and nurse must
ALL be present for debriefing.
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- What if the patient needs an interpreter or cannot represent
themselves, how do we do the Briefing section? If an interpreter or
representative/family member is present, complete the Briefing
section in the Pre Operative Holding Area with Circulating Nurse,
Anesthesia, and Surgeon present.
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- The Canadian Adverse Events Study Baker GR, Norton P, Flintoft
V, et al. The Canadian adverse events study: the incidence of
adverse events among hospital patients in Canada. CMAJ. 2004; 170
(11): 1678 - 1686. Impact of using the checklist at the eight WHO
pilot sites Haynes AB, Weiser TG, Berry WB, et al. A surgical
safety checklist to reduce morbidity and mortality in a global
population. New England Journal of Medicine. 2009 Jan 14; [Epub
ahead of print]. The Joint Commission Sentinel Event Data; Root
Causes by Event Type 2004-2012 Alberta Health Services Safe Surgery
Checklist Provincial Measurement Strategy September 17, 2012