Two Wrongs Making a Right:

February 1, 2003

Two Wrongs Making a Right:
AORN Pushes 'Patient Safety First' Campaign

By Kelly M. Pyrek

Medical errors and wrong-site surgeries had been making headlines long beforethe Institute of Medicine (IOM) issued a report in 2000 that focused on thesubstantial number of these errors, the financial cost and the resulting toll inpatient pain, suffering and death, but this report triggered numerousinitiatives within the medical community and in the government. Among thoseleading the charge is the Association of periOperative Registered Nurses (AORN)with its Patient Safety First initiative, a comprehensive patient-safetycampaign for implementation in operating rooms and surgical centers nationwide.

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)defines wrong-site surgery as any surgery performed on the wrong site or patientor performing the wrong procedure. To address this problem, it unveiled itssentinel event policy in 1996, providing a mechanism for healthcare facilitiesto report sentinel events such as patient injury, medication or equipment errorsand wrong-site surgeries. While the IOM report stated that medical errors areaccountable for as many as 44,000 to 98,000 deaths annually, the actualincidence of wrong-site surgeries is largely unknown - although several groupshave produced varying data. JCAHO says approximately 197 wrong-site surgerieshave been reported through the agency's sentinel event tracking system since1995. The Physicians Insurers Association of America reports 225 claims fororthopedic wrong-site surgery and 106 claims for other surgical specialties --data culled from 22 medical malpractice carriers representing 110,000 surgeons.

A Harvard University study reported that adverse events occur in 7 percent ofall hospital admissions; of those, short-lived disability resulted in 70 percentof the cases, while in 7 percent of cases, adverse events led to patient death.The study said medical errors account for as many as 180,000 deaths annually,more than are attributable to motor vehicle or workplace accidents.

Donna Watson, RN, CNOR, president of AORN, believes numbers like those fromthe IOM report are "significantly understated."

"We traditionally have practiced in cultures that have a tendency toplace blame on individuals when an error occurs vs. blaming a system,"Watson adds. "So you may have a lot of near misses but the healthcarefacility doesn't report them because it fears punitive actions willfollow." Watson says she knows of one facility that reported more than 75near misses in one month, and suspects this might be a common occurrence. Shesays AORN's Patient Safety First initiative includes the establishment of ananonymous error-reporting system to provide a safe forum in which healthcareproviders in the perioperative arena can report their transgressions and seekways of helping prevent future accidents. AORN has established a hotline and Website so healthcare professionals can ask safety-related questions, sharecomments and suggestions, and report concerns and/or incidences of surgicalerror. The Patient Safety First hotline number is (866) 285-5209; the PatientSafety First Web site is located at www.patientsafetyfirst.org.

Patient Safety First is sponsored by Sandel Medical Industries.

"We want nurses and doctors to be able to report errors and near missesanonymously so we can learn from their mistakes and take action to correctthem," Watson said. "We're looking for stories and information aboutwhat actually happens in the operating room."

There are numerous human factors in the perioperative setting that increasethe risk for wrong-site surgery, Watson says, and they include:

  • Incomplete or inadequate communication among surgical team members

  • Inadequate patient assessment or identification

  • Pressure to reduce operating room turnover time

  • Reliance solely upon the surgeon to determine the correct surgical site

  • A lack of uniform policies and procedures and control mechanisms

  • Special patient characteristics such as morbid obesity, etc.

  • Unusual equipment or unfamiliar set-up in the operating room

  • Illegible handwriting or use of abbreviations

  • Having more than one surgeon involved in a procedure or performing multiple procedures on multiple body parts during a single surgical encounter

In the end, it may come down to communication and team interaction, Watsonsays.

"From my experiences, on any given day, you have different teams comingin and out and it's amazing to see how well certain teams work together andothers that don't."

Teamwork is also needed between patients and surgical team members, Watsonemphasizes, alluding to the fact today's healthcare consumers are more informedthan ever before.

"We live in a society in which people are much more participatory intheir healthcare than in the past, so it's not unusual to have a patient show upwith a plethora of information when they come in for an office visit. My job isto sort out the information that is backed up by scientific research vs. poorinformation from unreliable sources. Having the correct information helps themmake informed decisions and encourages them to become more involved in theirsurgeries."

However, Watson cautions, "Having the patient more involved does notrelieve any healthcare professional from their duty of care. But in the past, itwas 'doctor knows best.' Today, while healthcare providers have the training andexpertise, sometimes it's not always them who know best; it's the patient who isliving the surgical decisions and it's the patient who must also participate inhis or her care."

AORN's "Advice for Patients Concerned About Correct Site Surgery"document is a set of guidelines for patients to use prior to undergoing asurgical procedure in order to ensure a positive outcome. The guidelines are:

1. Be an active member of your healthcare team by taking part in everydecision about your health care.

2. If you are having surgery or another invasive procedure, make sure thatyou and the healthcare professionals treating you all agree on exactly what willbe done during the surgery or procedure.

3. Verify the information on your patient identity bracelet. Alert a memberof the healthcare team if the information is incorrect and insist that it bereplaced immediately.

4. Make sure the operative permit you sign includes the correct informationabout your surgical site (i.e., right or left) and procedure. Thoroughly readall medical forms and make sure you understand them before you sign any forms.

5. Ask to have the surgical or procedure site marked on your body with anindelible marker. If possible, be involved in marking the site.

6. Ask questions and speak up if you have any concerns. Keep asking questionsuntil you understand the answers. Ask members of the healthcare team what stepswill be taken to ensure your safety and correct site surgery.

7. Take a responsible family member or friend to accompany you to yourdoctor's visits and on the day of your surgery or procedure so that they canserve as your advocate and speak up for you if you are unable.

8. Ask that your surgical team include a registered nurse who is a member ofAORN.

On the flip side, surgical team members can take the following actionsrecommended by AORN to ensure correct-site surgeries:

  • Engage in ongoing and effective communication

  • Encourage the patient to actively participate in the perioperative process

  • Maintain the highest levels of patient care

  • Practice interdisciplinary collaboration

  • Engage in accurate and legible documentation

AORN also suggests the following guidelines for creating a surgical-siteverification policy for your facility:

  • All patients undergoing surgery will have the surgical site, level and laterality confirmed by the entire surgical team before any procedure is performed

  • A checklist will be used for every surgical encounter to document verification of the surgical site

  • The verification checklist must be completed in its entirety; each person completing any portion of the checklist must initial that portion of the list and the surgery must be postponed if the checklist is incomplete

  • Any surgical site discrepancy noted during the verification process will result in an immediate halt of the surgery until the discrepancy can be resolved

Post-operative complications join the list of risks being monitored by JCAHO.In its review of 64 cases related to operative and post-operative complications,it found that 84 percent of these complications resulted in patient deaths while16 percent resulted in serious injury. Fifty-eight percent of the complicationsoccurred during the post-operative period; 23 percent were intraoperative; 13percent occurred during post-anesthesia recovery; and 6 percent were duringanesthesia induction. The most frequent complications were:

  • Nasogastric or feeding tube insertion into the trachea or a bronchus, usually involving failure to confirm placement

  • Massive fluid overload from absorption of irrigation

  • Open orthopedic procedures associated with acute respiratory failure and cardiac arrest in the operating room

  • Endoscopic procedures with perforation of adjacent organs

  • Central venous catheter insertion into an artery

  • Burns from electrocautery used with a flammable preparation solution

Facilities can help their healthcare personnel avoid complications byimplementing the following risk-reduction action steps:

  • Offering staff training and ongoing education

  • Standardizing procedures across settings of care

  • Defining channels of communication

  • Revising the competency evaluation process

  • Monitoring consistency of compliance with procedures

AORN will expand the Patient Safety First program to focus on additionalpriorities such as medication safety, infection control, counts and more. Thelist of safety areas to be addressed also includes patient positioning,communication, blood transfusion, retained foreign objects, burns, fires,equipment failure and staffing.

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