SDS Accreditation Update: Errors in surgery still are piling up, based on statistics from The Joint Commission
SDS Accreditation Update
Errors in surgery still are piling up, based on statistics from The Joint Commission
ACOG and AORN issue guidance to assist providers
A woman goes in for a hysterectomy, then begins to have pain and swelling. Over six years, abnormal cell tissue develops and is thought to be cancer. She undergoes an exploratory laparotomy, and a surgical towel is discovered in her abdomen. In December, the jury awarded her more than half a million dollars for pain and suffering.
Between March 31, 2010, and June 30, 2010, The Joint Commission sentinel events database received reports of 23 unintended retention of foreign bodies as well as 13 wrong-site surgeries. These numbers, compiled in such a short amount of time, have many outpatient surgery providers scratching their heads and asking, "How can these events still be happening?
Help is on the way. The Association of periOperative Registered Nurses (AORN) has updated its recommended practices for sponge, sharps, and instrument counts and renamed it the "Recommended Practices for Prevention of Retained Surgical Items." (For more on the AORN recommended practice, see story, below. See ordering information in resources.) Also, the American College of Obstetricians and Gynecologists (ACOG) has issued a revised committee opinion on "Patient Safety in the Surgical Environment."1 It includes a new section on "retained foreign objects."
Are outpatient surgery providers and others simply so busy that they put themselves at risk of sentinel events?
"I think that's part of it," says Patrice M. Weiss, MD, chair of ACOG's Committee on Patient Safety and Quality Improvement, which developed the committee opinion, as well as chair of the Carilion Clinic and professor at Virginia Tech Carilion School of Medicine and Research Institute, Department of OB/GYN, both in Roanoke, VA. Outpatient surgery providers can become complacent, Weiss says. "We let our guard down a little bit," she says. "We don't follow exact protocols, checklists, standard operating procedures."
Often is a perception among all of the members of an OR team that "it's just a minor procedure," Weiss says. "And then you leave a sponge in," she says.
The theme of the revised ACOG committee opinion is failed communication between all types of providers, all types of physicians, and with the patients, Weiss says. "One of things key to preventing wrong site surgical errors is to have patients participate in the time out," she says. Ask patients about the procedure, their date of birth, and any allergies, Weiss advises.
New wording in a section on freestanding surgical units focuses on the need to have the same level of safety, regardless of the setting. "If an endometrial ablation is done in an OR in a hospital, or in an OR or surgical suite of a freestanding center, our level of vigilance should be exactly the same," Weiss says. "While we want more procedure to be done in freestanding centers, we have to be sure the quality and consistency of care does not vary."
All of the committee members are "pro" when it comes to freestanding surgical units, she emphasizes. "They're efficient, there's better convenience of the patient, and less wait, but we have to make sure we don't deviate from one standard of care," Weiss says.
For example, if surgeons want to perform endometrial ablations in an office setting, do they have the same ability as a hospital or surgery center to response to hypotensive episodes? Patient vomiting and aspiration? Allergic reactions? "As long as the answer is yes, one can feel comfortable they're maintaining the same level of safety," Weiss says.
The committee opinion notes that more freestanding surgical units might seek accreditation in the future, and many states already require it, based on the level of anesthesia. "Such requirements will likely improve the quality and safety of care provided in these settings," the committee opinion says.
"What we're really asking people . . . is not uniform accreditation; it is to police themselves initially," Weiss says. "Make sure the provider, facility, and those assisting the surgeon are comfortable with the procedures and complications."
The committee has added a section on the World Health Organization (WHO) Surgical Safety Checklist. (For information on checklist, see resource box, p. 2.) "If we follow the checklist, go A-Z and never skip a letter, you won't forget a sponge count. You won't forget a time out," Weiss says. "What we're really talking about is standardization of processes."
A recent study found that U.S. hospitals could save money as well as improve care by adopting the WHO checklist.2 Based on data from Brigham and Women's Hospital in Boston and the U.S. pilot site in the WHO's Safe Surgery Saves Lives Study, the authors estimate the per-use cost at $11. Based on the eight sites in the WHO study, they estimate the checklist could reduce major surgical complications by 10%.
Follow safety checklists, and keep up your guard, Weiss advises. In terms of retained foreign objects, "even if it is a low probability of one in a million, it's not zero in a million," she says. ". . . [W]hen anyone is learning a new procedure, and you get comfortable with it, you don't ever want comfort to blend slightly into complacency."
References
- The American College of Obstetricians and Gynecologists, Committee on Patient Safety and Quality Improvement. Committee Opinion No. 464: Patient Safety in the Surgical Environment. Ob Gyn 2010;116:786-790. Doi: 10.1097/AOG.0b013e3181f69b22.
- Semel ME, Resch S, Haynes AB, et al. Adopting A Surgical Safety Checklist Could Save Money And Improve The Quality Of Care In U.S. Hospitals. Health Affairs 2010; 29: 1593-1599. Doi: 10.1377/hlthaff.2009.0709.
AORN: Entire team needs to be involved Retained items include towels, small needles The "Recommended Practices for Prevention of Retained Surgical Items" from the Association of periOperative Registered Nurses (AORN), which is a updated and revised version of the recommended practices (RP) for sponge, sharps, and instrument counts focuses on the involvement of the entire OR team. In the past, the RP focused primarily on the role of the RN circulator and scrub nurse, according to Ramona Conner, RN, MSN, CNOR, manager of standards and recommended practices at AORN. "As we've done literature reviews, the evidence has evolved over several years we've always known it, but it has become more clean the whole team needs to be involved in prevention of retained surgical items." Another change is that previously, most OR providers thought solely of sponges when they considered retained items. "There have been many incidences of retained surgical towels," Conner says. "We now refer to 'radio-opaque surgical soft goods,' and towels are included." One focus of the revised RP is reduction of unnecessary distractions and activities during the counting process. What distractions should be avoided? Running errands, multi-taking, and charting, Conner says. "We want to encourage people to focus on the count process and avoid distractions," she says. One major emphasis is measures that should be taken to reconcile count discrepancies, Conner says. "That recommendation has been greatly expanded and is much clearer," she says. "People will find it much more helpful, helping them develop a standardized process for reconciling count discrepancies." One misconception about counting that impacts outpatient surgery providers is procedures involving needles smaller than 10 mm. "Many people think you don't need to count those," Conner says. "That's not true." Members of the AORN staff advise that all suture needles need to be counted, regardless of size. However, needles smaller than 10 mm probably won't show up on an X-ray, Conner acknowledges. "The organization, in its policy, may want to specify whether or in what cases X-ray to identify a retained item might be waived," she says. One addition to the RP is the discussion of adjunct technologies, used to supplement manual count procedures, Conner says. There are a variety of technologies, such are radio frequency identification tags, being introduced to locate and count soft goods, she says. "It's exciting," she says. "We're just on the horizon of technology being developed that will help supplement human counting processes." The bottom line is that "organizations and professionals need to have consistent, reliable, and redundant processes for performing counts and retention of retained surgical items. " Conner says. Because counting is a human effort, errors can be made by any one, any time, at any point, she says. "Redundancy is critical," Conner says. "There should be multiple checks by multiple people." Resources The "Recommended Practices for Prevention of Retained Surgical Items" can be ordered from the Association of periOperative Registered Nurses (AORN) web site: www.aorn.org. Under "Practice Resources," select "Perioperative Standards and Recommended Practices." On the left side of the page, select "eDocument order form" The price is $55 for members and $95 for non-members. AORN customer service can be reached at (800) 755-2676 or [email protected]. The World Health Organization (WHO) Surgical Safety Checklist can be accessed at www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html. |
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