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Preventing surgical errors: the role of the surgical technologist
A synopsis of patient centered medical homes
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In the United States, hospitals and organizations find ways to help prevent events that should rarely or never occur, often called Never Events. The list of Never Events is made in order to provide hospitals with incentives to make sure the occurrences of them are reduced. As Mrs. Friend states, “If revenue decreases in our health care facilities because of “Never events” this could impact nursing in many ways. The rate of pay, staff to patient ration, availability of modern medical equipment, and our health insurance premiums will all be affected” (Friend, 2009, p. 5). One major type of Never Event that happens more often than it should is a surgical never event. Although, the occurrences of surgical Never Events may not be out of control, we must take into account that they are only reported if they are discovered. In today’s society the occurrence of Never Events should be virtually zero because of the technology available to prevent them. Surgical Never Events can happen very easily if procedures to prevent them are not used. Surgical Never Events include foreign objects left inside the patient, wrong site surgery, and performing the wrong surgery on a patient. “There were 148 surgical never events in England between April and September 2013, including one woman who had a fallopian tube removed instead of her appendix” (Nursing Standard, 2014, p.10). It is crucial for these surgical errors to never happen because they are often never caught and can potentially result in a fatality. When patients do not have complications in a reasonable amount of time after surgery the errors are often never found because when they start to cause an issue it is often too late. It is crucial for workplaces to enforce preventative procedures i... ... middle of paper ... ...hould publish data on serious incidents for independent review” (Nursing Standard, 2014, p.10). In order to fully decrease the amount of never events occurring staff members need to be fully trained on how to properly use checklists, how to prepare for a surgery, and how to conclude a surgery. These trainings will stress the necessity of using checklists, and because of it most Never Events that transpire will only be serious occurrences. Over time the occurrences of surgical Never Events has decreased with the help of checklists and other procedures implemented in the work place. Works Cited Friend, D. (2009). “Never Events” in healthcare: SB 435/HB 758. Maryland Nurse, 10(3), 5. Serious ‘never events’ listed in new bid to eliminate them. (2014). Nursing Standard, 28(27), 10. Sirounian, G. (2014). AAOS now. Using Checklists To Ensure Patient Safety. 8(3), 1.
Chasing Zero is a documentary which was meant to both educate the viewer on the prevalence of medical harm as well as to enlighten both the public and health care providers on the preventability of these events (Discovery, 2010). The documentary expounded on the fact each year more people die each year from a preventable medical error than die due to breast cancer, motor vehicle accidents or AIDS (Institute of Medicine, 1999). Medical harm can result from adverse drug events, surgical injuries, wrong-site surgery, suicides, restraint-related injuries, falls, burns, pressure ulcers and mistaken patient identities (Institute of Medicine, 1999). Incidences of medical error have been reported in the media for many years. The most startling revelation in the documentary is how common medical errors are and how preventable they are.
Popular television paint a glorified image of doctors removing the seriousness of medical procedures. In the non-fiction short story, “The First Appendectomy,” William Nolen primarily aims to persuade the reader that real surgery is full of stress and high stakes decisions rather than this unrealistic view portrayed by movies.
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.
With patient safety always being the number one priority FTR is the worst case scenario for the hospitalized patient. In an article titled “Failure to Rescue: The Nurse’s Impact” from the Medsurg Nursing Journal author Garvey explains ways FTR can occur “including organizational failure, provider lack of knowledge and failure to realize clinical injury, lack of supervision, and failure to get advice.” Nurses are problem solvers by nature, they heal the sick and help save lives. FTR is a tragic experience for everyone involved. The recent surge in this happening across the country has given FTR cases widespread media coverage. Hospitals are trying to figure out what the root cause is and how they can be prevented. Fortunately, with the advancement of technology and extensive research many hospitals have developed action plans and procedures to help prevent the early warning signs from being
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.
The term “safety comes first” or more simply put, “safety first,” is a message that patients not only want to hear, but also want to know is the focus of the professionals that are caring for them; in particular, when they are under anesthesia and have limited or no ability to speak up or lookout for themselves. The National Patient Safety Agency (NPSA) has implemented two initiatives; Rocognising and Responding Appropriately to Early Signs of Deterioration in Hospitalised Patients (NPSA, 2007) and How to Guide: Five Steps to Safer Surgery (NPSA, 2010). Understanding that human beings make up the healthcare professional workforce, it is evident that tools and checklist can and will only be as good as the how people utilize and follow them. Thus, these initiatives “have been developed with consideration of human factors” (Beaumont & Russell, 2012). I know firsthand, that if my healthcare team would have followed these standards, I would have avoided torture, fear, and long term side effects from a routine hysterectomy procedure.
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.
Hinkle, Janice L, Cheever, Kerry H. (2014). Brunner &Suddarth’s textbook of Medical-Surgical Nursing. Philadelphia: Wolters Kuwer/Lippincott Williams &Wilkins.
The treatment could be a medication, surgical procedure or some kind of therapy has an undesirable secondary effect which occurs in addition to the desired therapeutic effect. The causes of adverse effects vary for each patient, and depend largely on their general health, the state of their disease, age, weight, and gender. There are 3 main causes of adverse effects in procedural care. They are poor infection control, inadequate patient's management and failure of health care provider to communicate effectively before, during and after procedure. In poor infection control, a study found that surgical wound infections consider as the second largest category of adverse events. However, administration of prophylactic antibiotics has reduced the incidence of postoperative infections. In the second cause which is inadequate patient's management, the operating room and environment involve intensely complex activities involving a range of health professionals and should always include the patient when conscious. This may explain why more adverse events are associated with surgical departments than with other hospital departments. Also there are other factors contribute in a lot of adverse events in surgical care like inadequate implementation of protocols, poor leadership; poor teamwork, conflict between different departments/groups within the organization, inadequate training and preparation of staff, inadequate resources, lack of evidence based practice, poor work culture, overwork and lack of a system for managing performance. In the third cause, Miscommunication is one of the biggest problems in the operating environment. Miscommunication has been responsible for the wrong patients having surgery, patients having operations on the wrong side or site, and the wrong procedure being
In Medical Checklists Waste Time and Money, Max Rebarb calls medical professionals to stop using checklists in their workplaces. He considers the use of checklists to be unnecessary, costly, time consuming and ultimately a burden on health care systems. Flaws in the author’s statements includes: failing to remember that health care professionals aren’t perfect, forgetting that following lists can be time and cost effective, and disregarding the main goal of healthcare. As in many professions, checklists can actually be extremely valuable assets to a healthcare team.
ANA describes “The Scope of Nursing Practice (as) the “who,” “what,” “where,” “when,” “why,” and “how’ (8).’ In other words, it is the responsibility of the nurse to know who their patient is, what the patient’s diagnosis and treatment are, where it is they will be delivering treatment, the rationale behind their actions, and how they will deliver the care. By following the scope of practice, nurses reduce avoidable errors and are aware of the liability their actions entail. The ANA also puts forth a nursing process to guide nurses in treatment. The constantly evolving process is currently assessment, diagnosis, identification of outcomes, planning, implementation, and evaluation (ANA 9). Though this method has dramatically improved nursing care, it may be necessary to repeat steps to adapt to a patient’s changing needs and pathologies. By following guidelines set by the ANA, nurses are able to better connect with their patients and instill the image of professionalism to the public while also optimizing safety
It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).
Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency coordination task force with the help of government agencies. These government agencies are responsible for making health pol-icies regarding patient safety to which every HCO must follow (Schulman & Kim, 2000).
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
The health care is extremely important to society because without health care it would not be possible for individuals to remain healthy. The health care administers care, treats, and diagnoses millions of individual’s everyday from newborn to fatal illness patients. The health care consists of hospitals, outpatient care, doctors, employees, and nurses. Within the health care there are always changes occurring because of advance technology and without advance technology the health care would not be as successful as it is today. Technology has played a big role in the health care and will continue in the coming years with new methods and procedures of diagnosis and treatment to help safe lives of the American people. However, with plenty of advance technology the health care still manages to make an excessive amount of medical errors. Health care organizations face many issues and these issues have a negative impact on the health care system. There are different ways medical errors can occur within the health care. Medical errors are mistakes that are made by health care providers with no intention of harming patients. These errors rang from communication error, surgical error, manufacture error, diagnostic error, and wrong medication error. There are hundreds of thousands of patients that die every year due to medical error. With medical errors on the rise it has caused the United States to be the third leading cause of death. (Allen.M, 2013) Throughout the United States there are many issues the he...