Dr. Shailendra.V.L.Director Patient Safety

Bukairyah General Hospital

Sample Events 

The Anesthesia Care Provider inserted the needle to perform an anesthesia block. The patient felt a twitch in her leg and stated that the twitch was on the left side and the surgery should be on the right side. The patient was correct. No site marking or Time Out had been performed prior to

the block. Site mark for right stent placement placed on arm

and was not visible after prepping and draping. Left stent placement performed. Site mark was not visualized during the Time Out.

Sample Events 

Surgeon consulted on patients in two different rooms. Surgeon performed knee aspiration on incorrect side thinking it was the other patient. Patient identity was not verified and Time Out was not

performed. Patient consented to left knee arthroscopy. Right

leg placed in holder and tourniquet placed. Surgical site had been marked but when initials were not seen on the right leg surgeon thought mark was removed by surgical prep.  Site marked was not visualized during the Time Out.

At-risk Behaviour in the OR

Not checking equipment before use Surgeon entering after prep and drape Surgeon running 2 rooms Multi-tasking from O.R. Relying on memory about the pathology Unannounced substitutions in mid case Continuing to close during sponge

search

Impact of Wrong Site Cases

Patient harm, sometimes loss of limb or life Physical injury and possibly assault Loss of faith in the healthcare providers Surgeon litigation and licensure penalties Hospital litigation and accreditation

penalties Indefensible public image risk Undermines surgery team cohesion

5

Objectives of Safe Surgery

The team will operate on the correct patient at the correct site

The team will use methods known to avoid harm from the administration of anesthesia, while protecting the patient from pain

The team will recognize and effectively prepare for life threatening loss of the patient’s airway or respiratory function

The team will recognize and effectively prepare for the possibility of high blood loss

The team will avoid inducing any allergic or adverse drug reaction known to be a significant risk for the patient

Objectives of Safe Surgery

The team will consistently use methods known to minimize the possibility of surgical site infection

The team will work to avoid the inadvertent retention of instruments or sponges in surgical wounds

The team will secure and accurately identify all surgical specimens

The team will effectively communicate and exchange critical patient information for the safe conduct of the operation

How to avoid such mishaps

High Reliability Organisations - CARE Commitment by the Leaders Attention to the Task Respond as a Team Effective Communication

O.R. Team Should Be Patient-focused

Not surgeon-focused Not workflow-focused Not specialty-focused Not budget-focused Not break-focused

Surgical safety checklist

Sign in Time out Sign out

Strengths of the Surgical Safety Checklist

Deployable in an incremental fashion Supported by scientific evidence and

expert consensus Evaluated in diverse settings around the

world Ensures adherence to established safety

practices Minimal resources required to implement

a far-reaching safety intervention

Guiding Principles

Simple Widely applicable Measurable Address serious and avoidable surgical

complications Zero harm from the Checklist

What issues does this checklist address?

◦ All important safety elements are reviewed by ALL OR teams, for ALL patients, at ALL times

◦ Promote teamwork and communication Communication is a root cause of nearly 70% of the events

reported to the Joint Commission from 1995-2005.◦ Preparedness for the unexpected◦ Promotes an environment that allows anyone on

the team to speak up if patient safety is at risk◦ Correct patient, operation and operative site◦ Safe Anesthesia and Resuscitation◦ Minimize the risk of infection

(17) Surgical Safety Checklist; Sign In

No.ActivityFMPMNMNA1Sign In instructions is done before induction of anesthesia   

2The patient confirmed his/her identity, site, procedure and consent   

3The surgical site has been marked   

4Known allergy is verified   

5Difficult airway/aspiration risk is verified   

6If difficult airway/aspiration risk exist, equipment/ assistance is available   

7

If there is risk of >500ml blood loss (7ml/kg in children), adequate IVaccess/fluids is planned

   

8

Antibiotic prophylaxis, if indicated, has been given within the last 60minutes

   

9Confirm that VTE prophylaxes, if indicated, has taken place.   

)18 (Verification Process/Time Out

No.ActivityFMPMNMNA

1Time- Out is done before skin incision and before starting anesthesia, andis read out loud

   

2Time- Out is done with nurse, anesthetist and surgeon or his/ her designee   

3The surgeon or his/ her designee, anesthetist and nurse verbally confirm the patient’s name.

   

4The surgeon, anesthetist and nurse verbally confirm the procedure.   

5The surgeon provides information regarding the critical or non-routinesteps, if any.

   

6The surgeon provides information regarding how long will the case take.   

7The surgeon provides information regarding how much blood loss isanticipated

   

8The anesthetist provides information regarding any patient-specificconcerns.

   

9The nurse has confirmed the sterility of the instrumentation (includingindicator results).

   

10The nurse has confirmed whether there are equipment issues or concerns.   

11The team ensures essential radiology imaging are displayed.   

)19 (Surgical Safety Checklist; Sign Out

No.ActivityFMPMNMNA

1Sign out instructions is done before patient leaves operating room and isread loud.

   

2Sign out is done with nurse, anesthetist and surgeon or his/ her designee.  

3Nurse verbally confirms the name of the procedure.  

4Nurse verbally confirms completion of instrument, sponge and needle counts   

5Nurse verbally confirms specimen preservation (dry, formalin, saline orwater)

   

6Nurse verbally confirms labeling of the specimen with 2 patient identifiers.   

7Nurse verbally confirms whether there are any equipment problems to beaddressed

   

8Surgeon, Anesthetist and Nurse confirm the key concerns for recovery andmanagement of this patient.

 

  

Factors contributing to failures

“Captain of the Ship” mentality Surgery team hierarchy Culture of blame and punishment Compelling incentives for speed Little attention to near misses Failure to adopt “best practices” Litigation and confidentiality

Success stories

An elderly patient undergoing repair of a hip fracture was prepped for a right-sided procedure, consistent with the consent, history and physical, and a consultation report. During the time out, the surgical team determined that the patient had a left hip fracture, which was then confirmed by x-ray. The procedure was performed on the correct side.

Wrong knee was marked in pre-procedure area. Verification of the site marking against source documents uncovered the discrepancy and correct site was marked and surgery completed.

Take-Home Points

A Time Out must be completed prior to any invasive procedure across the organization for every patient, every time

All Time Outs must be completed following the 5 key steps in the Time Out process

If there are any discrepancies during the Time Out or a step is not completed, members of the team will “Stop the Line” until resolution and agreement by the team

Staff and physicians will be supported by administration in “Stopping the Line.”

Conclusion

Wrong site and wrong patient surgery remains a problem

Eliminating wrong site and wrong patient surgery will require widespread utilization of principles of error management, accepting safety as a core value

Healthcare leaders need to embrace a commitment to studying our mistakes, developing best practices and sharing solutions nationwide