This is the third article in a series of five articles focused on the most pressing issues in patient safety and infection control, published during International Infection Control Week. The series is sponsored by X-STATIC®. Access the first article on hand hygiene here. Access the second article on safe injection practices here.
Operating rooms need to be collaborative, supportive environments in order for hospitals to improve patient safety, says Gina Pugliese, RN, MS, vice president of Premier's Safety Institute. Hospitals have made great strides in using surgical checklists and reminders to make sure critical tasks don't slip through the cracks — but there is still work to be done. Here she outlines seven strategies for improving teamwork and avoiding errors in the operating room.
1. Use first names in the OR. An important part of OR culture is making sure all the people in the operating room work as a team, Ms. Pugliese says. "Everyone should feel comfortable speaking up," she says. "That's been a challenge for years in the OR, in particular because the surgeon was always in charge and the residents were afraid to ask questions." She says hospitals have to take action to reverse this culture, which privileges hierarchy over patient safety.
One simple way to do this is to ask everyone to use first names in the OR — even the physicians. "You have to be able to feel that you're all on the same page," she says. At the beginning of the surgery, everyone should go around the room and say their first name and their role in the operating room, to increase the sense of unity.
2. Emphasize the importance of the pre-surgical briefing. Most hospitals conduct a 'briefing' at the beginning of every surgery to go over the surgical checklist and introduce the patient. Every hospital includes different items in their checklist and time-out procedure, though professional organizations and CMS recommend certain items. At the beginning, the surgeon should introduce the patient, his or her age, and any co-morbidities or issues to watch out for during the procedure.
At that point, the team should go through the checklist together — with no interruptions or other tasks happening at the same time — and note who is responsible for each task. This increases the burden of responsibility on each provider and makes sure that no tasks are forgotten because someone thought someone else was taking care of it.
3. Ask physicians to consider blunt-suture needles. Hospital ORs still struggle with injuries, generally involving sharps such as scalpels. "There's been some wonderful work done with blunt suture needles that just never really took off," Ms. Pugliese says. "That's unfortunate because there's a role in the operating room for the use of blunt suture needles, and it's been shown to reduce sticks."
She says part of the resistance is about knowledge: Many surgeons believe that sharp-suture needles are more effective and do not have a physician role model to convince them otherwise. In order to introduce blunt suture needles to the OR effectively, she says you need a physician champion. "You need buy-in from a surgeon leader who will be an early adopter and show that safety scalpels are just like regular scalpels," she says.
4. Communicate well during hand-offs. Perfecting transitions of care is extremely important in the OR, because providers may not have a clear grasp of the patient's condition or history when taking over care. "The handoffs between the OR and the PACU are probably some of the most important communication that goes on," Ms. Pugliese says. She says some hospitals have implemented checklists that go over exactly who is responsible for transmitting each piece of information.
For some procedures, the checklist will specify that a nurse professional needs to be in the room for the hand-off; for others, the checklist will say that a scrub tech is sufficient. "One hospital I know implemented the script and measured their success by whether they had to call anesthesia or the physician within a certain number of hours after the transfer," she says. "If they called, it meant they needed more information and the transfer could have been better."
5. Use creative reminders for antibiotic timing. Ms. Pugliese says hospitals have improved significantly at antibiotic timing in the OR, meaning the patient receives an antibiotic in the hour before incision and discontinues that antibiotic within an hour after surgery. She says she has seen many creative approaches to antibiotic timing.
In one hospital, the patient and provider had to walk under a hallway arch that displayed a reminder sign; in another, an electronic reminder popped up in the patient's chart and had to be "accepted" before surgery could continue. In another, the patient's IV bag was hanging on a hook on the wall, not on the IV pole, so when the patient was taken to the OR, the IV bag was unhooked as a reminder to give the antibiotic.
6. Automate systems to reduce errors. One of the biggest challenges in a hospital is making sure patients are put on the right medication. There may be five or six physicians consulting with a patient, resulting in many conflicting medications. Patients may also come into the hospital already taking a medication that needs to be discontinued for surgery and then resumed after the operation.
Ms. Pugliese says medication reconciliation requires a level of standardization found most easily through an EMR. The EMR should contain specific forms that list the patient's medications for every type of provider. "Everybody can glance at the form and see what the patient's on in that moment of time," she says.
7. View "near misses" as a gift. Ms. Pugliese says hospitals need to eliminate the "culture of blame" that pervades our society. When something goes wrong, she says the natural tendency is to look for a culprit: Whose fault was it? Who didn't do what they were supposed to do? She says while an individual may be responsible for a mistake, usually it can be tied to a "systems breakdown," where the lack of a checklist or a system of checks and balances allows tasks to fall through the cracks.
She says hospitals should instead step back and view "near misses" — situations where something almost went wrong, but didn't — as a gift. It gives the OR team a chance to assess what happened during the surgery and determine what went wrong to allow the near-miss to occur. She says it's important to include front-line workers in these discussions, because often they can identify systemic problems that frequently cause issues with patient safety. "Maybe the staff doesn't have enough IV pumps that have programmable ways to prevent medication errors, so they have to use the other ones," she says. "You want to know what keeps staff up at night, what bothers them."
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