The NSPSS will commence in the am with a discussion on
Patient Safety Definitions, Goals and Recommendations. This is a highly
condensed version of the summary the group compiled prior to the meeting.
My questions/concerns are in red. I am sure this discussion
will be lively.
Aug 5 2016 NSPSS WORKGROUP 1: SAFETY
DEFINITIONS:
GOAL: identified and defined essential
surgical safety elements and processes, as well as the multiple teams involved
responsible for all phases of the surgical care continuum.
The quest for the
achievement of surgical safety occurs in a background of many challenges.
Patients often enter this system with complex co-morbidities, poor family
support and limited or no health literacy. The healthcare system is challenged
by a disjointed system wrought with potential human factor, instrument,
equipment, infrastructure and other system failures. The possibilities for
technical and non-technical slips, lapses or mistakes are endless. Transitions
between phases of surgical care are plagued with loss of critical patient
information and propagation of misinformation. While multiple professions are
charged with the responsibility of coordinating challenging aspects of surgical
care, surgeons are "uniquely obligated ethically and professionally to
serve as the patient's navigator and advocate".
Important safety element to optimize implementation of safety cultures:
1 . Surgical
leadership must optimize team performance and advocate a 'Culture of Safety'
using open respectful communication, setting the expectations, coaching towards
performance improvement, managing / facilitation conflicts.
2.
Surgical leaders must perfect
non-technical skills via establishment of psychological safety and advocating a
shared mental model, utilize standardized evidence based surgical clinical
pathways, adopting locally endorsed checklists, collect and follow safety data,
endorse high reliability principles in surgical teams (see below).
3.
Surgical leaders endorse the use
of safety technology demonstrated to reduce patient harm (??)
4.
Surgical leaders are committed to
the establishment and maintenance of safe surgical environment thru policies
and values which provide core surgical teams with the skills and knowledge to
proceed safely, optimize team performance including minimization of fatigue
effects, optimize nurse-patient ratios, maintain an undistracted situationally
aware team via elimination of distractions, prioritize safety as essential,
assuring the sufficiency of supplies, equipment, etc.
To assure everyone is on the same page, the workgroup utilized these
definitions for consistency:
1.
ADVERSE EVENT: any event during episode of care directly or indirectly resulting in
temporary or permanent harm
2.
NEAR MISS EVENT: event risking patient harm
3.
WRONG EVENT SURGERY- wrong site surgery-wrong patient, wrong surgical side, wrong spinal
level, wrong implant or wrong procedure.
4.
HIGH RELIABILITY PRINCIPLES
(Weick and Sutcliff):
a.
Pre occupation with failure: the
organization acknowledges the inevitability / potential for failure and
therefore has a grasp of human fallibility, system complexity, ambiguity,
uncertainty, limitations of training effects of distraction and fatigue, dynamic
conditions, time constraints and system vulnerabilities. They focus on
potential or actual adverse events. Their incident reporting system is designed
for organizational learning and improvement (not punitive).
b.
Sensitive to operations: they
continually evaluate local operational team and system performance with focus
on the successful and failed intervention.
c.
Reluctance to simplify: they do
not simply accept the first or easiest explanation to the etiology of adverse
event but investigate these thoroughly to find out "what went wrong"
as opposed to "who went wrong".
d. Commitment to resilience: knowing that errors
are inevitable, they have adaptable team and redundancies to mitigate risks of
harm preventing disruption of routine workflow.
e.
Deference to expertise: use of
team situational leaders who speak up (and are listened to) when they have
concerns.
5.
CULTURE OF SAFETY: accepts that the environment is high risk and error
prone, maintains a blame free structure support, encourages collaboration
without hierarchy, willingness to direct needed resources to address safety
concerns, and is vigilant towards improving they environment while expecting
untoward events.
6.
SURGICAL TEAM: group of care providers responsible for providing direct care
during multiple specific phases of surgical care (i.e. preoperative, immediate
preoperative, intraoperative, postoperative and discharge phases). The core
team always includes the surgeon, patient and the patient’s family.
7.
PERIOPERATIVE SURGICAL SAFETY / RISK REDUCTION STRATEGIES:
a. Preoperatively:
i. Surgeon /
patient shared decision making and informed consent at educational level /
language appropriate for the patient; Medical comorbidity and lifestyle
optimization (when possible); risk assessment using available tools (ACS/NSQIP
calculators); Hospital approved preoperative safety element (lab/x-ray
guidelines, HP etc.).
ii. Site Marked:
Utilize a uniform standard surgical site marking using surgeons INITIALS on the
PLANNED SURGICAL SITE in the pre-op holding area immediately
before (WHAT?) the planned surgery with
confirmation by an alert and informed patient.
b. Immediate preoperative phase: assess
readiness just prior to the patient being brought into the OR utilizing
hospital and provider approved preoperative surgical bundles designed to
eliminate errors, optimize patient outcomes and
reduce excessive variability in clinical practice-that is if every surgeon then
does something different it is next to impossible for the nurses to participate
safely in safety checklist support (especially if there are staff rotation or
new staff). By obtaining consistency the nurses theoretically spend less time
on the variable and more on the patient. Having said that variability can be
expected depending on the case type and patient type. WHERE AND HOW IS THIS
DONE? Bedside briefing? This may not be possible in many institutions where
workload production is the highest priority and the surgeons are pulled in many
different directions (OR, Ward, Office, administrative duties...).
c. Intra-operative:
i. OR safety
Processes (safe patient positioning/padding, secure transfers, fire and burn
safety)
ii. Distraction Free surgical environment: enforced by
policy.
iii. OR SURGICAL CHECKLIST (why is this here?
What does this mean?)
iv. Team Brief- surgeon led discussion prior to the case
- before induction of anesthesia with all surgical team members present. (where? w/ whom?) Discuss specific needs, special
concerns, and contingencies; using a shared mental model w/ psychological
safety; review of essential elements of checklist (pt id, procedure, consent,
site mark, anesthesia checklist, allergies, blood products, etc.)
v.
Surgical Time Out with a check list- Surgeon announced, full stop, full
engagement (Introductions- encouraged by not mandated,
should not disrupt flow such as anesthesia demands- the patient is asleep or
anxious so the faster this goes the better). Patient name, BD/SSN,
consent present, site marked. Anesthesia confirmation of abx.
vi.
De-brief: Procedure name, sponge count,
specimen labels, disposition plans. (then what went well, what needs to be
changed, what will we do differently?)
vii.
Use of Surgical Bundles: hypothermia, glucose control, VTE P, ABX, Intraop
medication use, wound management, team safety, sponge counts, Patient
disposition.
d.
Postoperative Surgical Care bundles.
e.
Cross phase tools: Consistent, unambiguous, effective, succinct hand off
communication.
NSPSS RECOMMENDATIONS-
A.
SAFETY
CHECKLIST:
1.
Consistent
use of all communications tools contained in the OR surgery checklist- surgical
team brief, surgical team time out and surgical team de-brief- with active
participation by all surgical team members for all surgical patients and
surgical procedures in all surgical settings.
2.
All
surgical facilities must provide regular OR-SC training and education programs
with compliance monitoring to assess proper use by all surgical team members.
3.
Surgeon
leadership supported by administrative facility safety commitment is key to
development, implementation and maintenance of effective OR-SC use.
4.
Surgical
facilities should develop and implement OR SC based on the WHO model with local
modifications as appropriate.
B.
SITE
MARKING: Site marking policies and programs should include:
1.
The
surgeon OR A DESIGNATED LICENSED INDEPENDENT MEDICAL PRACTITIONER, should
correctly identify, verify and INITIAL the planned surgical procedure site.
2.
SS
marking is best performed in the pre-surgical OR holding area immediately
before the surgical procedure.
3.
Site
should be marked with surgeons initials (blue or black indelible ink in legible
block style letters) directly over the location of the planned surgical
procedure (where it will be clearly visible within the surgical field following
positioning, prepping and draping) with simultaneous verification of the
planned surgical site and surgical procedure by an alert informed patient prior
to sedation and surgery. DO NOT USE X’s, Yes’s or No’s.
C.
SHARED
DECISION MAKING BETWEEN THE PATIENT and THE SURGEON: Patient is invited by the
surgeon to share in the decision making including discussions behind the reason
for surgery, alternative treatment options, beneficial outcomes and RISKS,
options for choice of surgical facility, disclosure of surgeon performing the
procedure, discussion regarding Advanced Directive (resolution of
inconsistencies between AD and necessary post-op care), time for questions and
answers (consider use of a checklist to inform the discussion between the
surgeon and patient).
Follow AHRQ limited
Health literacy by assuring material is at appropriate educational level,
assure comprehension and avoid medical jargon.
ACGME and ABMS should
include Share-decision making as requirements for surgical residency and for
surgeon credentialing.
D.
CONSENT:
1.
The
surgeon as the primary patient advocate supported by the surgical team and
surgical facility share accountability for an informed, timely and accurate
surgical consent document and process.
2.
All
errors or ambiguity in a surgical consent must be resolved prior to the patient
entering the OR.
3.
All
surgical facilities should define and consistently use a standardized safe
surgical consent process and document containing:
a.
Patient
centered, easily readable, and readily understandable consent form
b.
Use of
understandable language and surgical team speak with patients.
c.
Continual
use of patient feed-back for improved patient understanding and surgical team
verification.
d.
Absence
of use of complex medical/legal jargon
e.
The
consent process should include comparison and verification of patient name /
identity, procedure, and surgical site from the medical record/surgical
scheduling document and consent document.
f.
ACGME
should include knowledge and training of the surgical consent process as a
requirement for surgical residency.
g.
The Joint
Commission and similar surgical facility credentialing organizations should
include assessment of the surgical consent process as a component of surgical
safety programs.
h.
ABMS
should include knowledge of the surgical consent process as a requirement for
credentialing.
E.
INFORMATION
SHARING- “the Handoff”:
1.
All
surgical team members should be educated and trained to use standardized
communication tools to support accurate and efficient information transfer for
all transitions of surgical patient care.
2.
All
facilities should adopt, support and monitor use of standardized communication
tools to improve the accuracy and efficiency of surgical information transfer
during the entire episode of care.
3.
Hand off
tools should include:
a.
Distraction
free environment (not sure how in facilities where each nurse has
more than one patient).
b.
Face to
face communication (if this is for call check out that may not
be possible and other electronic means should suffice to do that):
c.
Clear
unambiguous transfer of responsibility
d.
Opportunity
to question, clarify and challenge the information
e.
Written
documentation of the transfer.
4.
EMR
should support these tools.
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