Review of Literature
Preventing the retention of foreign bodies and wrong site surgery Patient’s safety is important when they are having any surgical procedures performed. Many of the harms associated with healthcare are preventable. A report from Institute of Medicine in the United States (Kohn et al 1999) estimated that as many as one million people were injured and 98,000 individuals died annually as a result of medical error. (McCaughan & Kaufman) (2013) (p.48). There are always risk when having any kind of medical procedure done, but the outcome depends on the medical staff and how they handle the patient and take the right steps to prevent any harm to the patient. According to Donabedian (1968), quality of care ‘encompasses technical
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Surgical procedures are at risk of retention of foreign bodies or wrong site surgery. When looking at these events you should understand that everyone is at risk that has any surgical procedure performed. A comprehensive literature search was performed on Medline, Embase, the Science Citation Index and Google Scholar for articles published in English between January 2000 and June 2012. The incident of retained surgical instruments varied from 1 in every 1,000 to 1,500 intra-abdominal operations in studies suggest an incidence of 1 in 5,500to 1 in 18,760 inpatient operations. These studies implicate the surgical personnel involved in these operations as the prime offender. Surgical complications vary and often result in errors or omissions in practice. The most errors are wrong site surgery, wrong procedure and retained surgical instruments. (McDowell & McComb) …show more content…
The National Patient Safety Goals identified by the Joint Commission are designed to enhance patient outcomes in numerous strategic areas. AORN J 92 (October 2010) 420-242. Communication and collaboration in patient care settings is vital for promoting the best possible patient outcome. The counting of sponges, sharps, and instruments, and the surgical time out before the start of any surgical procedure are opportunities for the surgical team to address patient safety risks. Time out remains the key weapon in the fight against wrong site surgery. AORN J 97 (2013). Effective communication is essential to prevent wrong-site surgery and includes verifying the proposed surgical procedure and conducting a time out with verbal participation from the perioperative RN, anesthesia professional, surgeon, and scrub person. In addition, perioperative personnel should hold preoperative briefings and postoperative debriefings to address patient related concerns and other team member concerns. AORN. J 99
Orlando Regional Healthcare, Education & Development. (2004). Patient Safety: Preventing Medical Errors. Retrieved on March 2014 from world wide web at http://www.orlandohealth.com/pdf%20folder/patient%20safety.pdf
The Institute of Medicine (IOM) reported in 1999 that between 44,000 and 98,000 people die each year in the United States due to a preventable medical error. A report written by the National Quality Forum (NQF) found that over a decade after the IOM report the prevalence of medical errors remains very high (2010). In fact a study done by the Hearst Corporation found that the number of deaths due to medical error and post surgical infections has increased since the IOM first highlighted the problem and recommended actions to reduce the number of events (Dyess, 2009).
Hospitals are busy places, and with so much going on it is hard to believe that mistakes are not made. However, there are some accidents that should never happen. Such events have been termed ‘never events’ because they are never supposed to happen. This term was first introduced by Ken Kizer, MD, in 2001 (US, 2012). The Joint Commission has classified never events as sentinel events and asks that hospitals report them. A sentinel event is defined as, “an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof” (US, 2012). Never events are termed sentinel events because in the past 12 years 71% of the events reported were fatal (US, 2012). Because these events are never supposed to happen, many insurance companies will not reimburse the hospitals when they occur. A study in 2006, showed that the average hospital could experience a case of wrong-site surgery, one example of a never event, only once every 5 to 10 years (US, 2012). This study illustrates how rare a never event is. Hospitals do not want these never events to happen any more than a patient does. To help prevent these errors, hospitals have created policies that, if followed, will minimize the possibility of a mistake. The consequences of never events are devastating and because of this the goal is to make sure that they are eradicated from hospitals and medical facilities.
There are couple facts that have occurred in this case study, Dr. Jones doesn’t seem to have the proper staff in order to accommodate any further complications that might occur during the surgery. Dr. Jones didn’t necessarily have to have three procedures that involved three different anesthesia procedures. Mr. Smith overpaid for his procedures when he could have had the problem fixed in one appointment for only $2,000. I am personally not very familiar with these types of procedures which why these are the only facts that I can point at this moment. When it’s all said and done, Dr. Jones made his overhead and Mr. Smith is well because of the procedures done.
National Health Service (NHS) England. (n.d.). Five Steps to Safer Surgery Film [Video File]. Retrieved from http://www.nrls.npsa.nhs.uk/patient-safety-videos/five-steps-to-safer-surgery/
Surgical errors are seen in every hospital; however, hospitals are not required to report such incidents. Unintended retained foreign objects, often abbreviated as URFOs, are among those events that are often not reported.
Hospital medical errors can involve medicines (e.g., wrong drug, wrong dose, bad combination), an inaccurate or incomplete diagnosis, equipment malfunction, surgical mistakes, or laboratory errors. High medical error rates with serious consequences occurs in intensive care units, operating rooms, and emergency departments; but, serious errors that harmed patients may have prevented or minimized. Understand the nature of the error
Wrong site, wrong procedure, and wrong patient errors are avoidable safety issues. Nearly 1.9 trillion dollars are spent on medical errors each year in the United States (Catalano & Fickenscher, 2008). Between 1995 and 2007, 691 wrong-site surgeries have been reported to The Joint Commission's Sentinel Event data repository (AHC Media LLC, 2008). In 2003 in response to the outcry for better patient safety The Joint Commission published their National Patient Safety Goals. Among the goals was the Universal Protocol. The Universal Protocol is actually drawn from several of the National Patient Safety Goals. It relies on multiple check points and the involvement of the entire surgical team to avoid such errors. Wrong site, wrong procedure, and wrong patient surgeries should never happen. The Universal Protocol is an evolving process which reflects the success and failures of healthcare practice, thus it requires periodic updates and policy revisions.
Retained foreign objects have been a major problem throughout operating rooms, labor and delivery, as well as any other procedural area that perform invasive procedures. Retained foreign objects include soft goods, such as sponges, needles, sharps, instruments and other small miscellaneous items used during a procedure (NoThing Left Behind, 2013). The retention of these items can lead to several complications such as a local tissue reactions, infection, obstruction of blood vessels, and even death (Mathias, 2013, p. 2) According to the OR Manager, the effects of a retained surgical item can lead to patients having a increased mortality rate by 2.14%, an increased hospital stay by 2.08 days, and increased hospital costs by $13,315 (Mathias, 2013, p.1). In response to this, NoThing Left Behind was created. NoThing Left Behind is a national surgical safety project that was created as a system wide policy to help prevent the event of a retained surgical item (RSI). This project estimates that there are 1500-2000 retained surgical items left in patients each year within the United States (NoThing Left Behind, 2013). Furthermore, evidence shows that there has been an increase in retained foreign objects left within patients that undergo invasive procedures that occur outside of the operating room and labor and delivery. Therefore, the focus of this paper is to analyze the negative impact, physically, emotionally, and financially, on patients as well as the hospital, related to retained foreign objects during an invasive procedure. The focus is on areas such as the catheterization lab, endoscopy, emergency room, and other bedside procedures where there is no accounting process in place.
Safety is a primary concern in the health care environment, but there are still many preventable errors that occur. In fact, a study from ProPublica in 2013 found that between 210,000 and 440,000 patients each year suffer preventable harm in the hospital (Allen, 2013). Safety in the healthcare environment is not only keeping the patient safe, but also the employee. If a nurse does not follow procedure, they could bring harm to themselves, the patient, or both. Although it seems like such a simple topic with a simple solution, there are several components to what safety really entails. Health care professionals must always be cautious to prevent any mishaps to their patients, especially when using machines or lifting objects, as it has a higher
Safety is focused on reducing the chance of harm to staff and patients. The 2016 National Patient Safety Goals for Hospitals includes criteria such as using two forms of identification when caring for a patient to ensure the right patient is being treated, proper hand washing techniques to prevent nosocomial infections and reporting critical information promptly (Joint Commission, 2015). It is important that nurses follow standards and protocols intending to patients to decrease adverse
The Joint Commission was founded in 1951 with the goal to provided safer and better care to all. Since that day it has become acknowledged as the leader in developing the highest standards for quality and safety in the delivery of health care, and evaluating organization performance (The Joint Commission(a) [TJC], 2014). The Joint Commission continues to investigate ways to better patient care. In 2003 the first set of National Patient Safety Goals (NPSGs) went into effect. This list of goals was designed by a group of nurses, physicians, pharmacists, risk managers, clinical engineers, and other professionals with hands-on experience in addressing patient safety issues in a wide variety of healthcare settings (TJC(b), 2014). The NPSGs were created to address specific areas of concern in patient safety in all health care settings.
The National Patient Safety Goals are a key when it comes to patient safety. Implementing safety goals helps reduce the number of medication errors, improves communication between members of the healthcare team and reduces the number of infections patients acquire while under the hospital’s care. In addition, The Joint Commission reviews and publishes these goals each year. Depending on the occurrence of sentinel events, the goals are re-evaluated or revised accordingly. It is important that The Joint Commission reinforce the practice of patient safety goals in that they help improve patient care.
Despite the frequency of verbal interactions, miscommunication of patient information occurs that can lead to patient safety issues. . . . ‘Effective communication occurs when the expertise, skills, and unique perspectives of both nurses and physicians are integrated, resulting in an improvement in the quality of patient care’ (Lindeke & Sieckert, 200...
Time out was done by the anesthesiologist, the circulating nurse, the surgeon, and the scrub tech all pausing before the surgery and verifying the patient’s name and date of birth, the procedure being done, the site and location on the body in which the procedure was being done, and documented the count of all the equipment the scrub nurse had before surgery to compare to after surgery. 5. The patient’s privacy was protected and respected throughout the whole surgical procedure. The staff was very professional and I felt I learned a lot from them during my OR experience. 6. A sponge count is when the scrub nurse counts the sponges that are unused before the surgery she relays this to the circulating nurse and it is documented. After the surgery the count is redone to make sure that there are no sponges left in the patient. 7. The circulating nurse documents the information and signs the chart in the operating room. From pre-op to the operating room the nurses in pre-op gave off report to the circulating nurse by SBAR. From the operating room to PACU the anesthesiologist went with the patient and handed off the patient’s condition and information to the nurse in there. 8. There were no ethical or legal issues that were raised during my observation in the whole surgical process. 9. I learned how the whole operating procedure works from start to finish, all the legal paperwork involved, and how the team interacts and helps each other out to give the patient a safe and