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Wrong-site surgery cases
Best practice for surgical safety checklists
Wrong-site surgery cases
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Introduction to the dilemma
Ensuring proper patient safety in the operation room starts prior to the patient entering the operation room. Special attention is given by the hospital staff to prevent surgical errors. Surgical errors consist of wrong-site, wrong-person, wrong-procedure, and retained foreign object(s). Wrong-patient surgery refers to a surgical procedure performed on an alternative patient rather than the patient who was intended to undergo the operation. The wrong-side surgery means a surgical procedure done on the incorrect extremity of the patient’s body. For example, in one case a patient needed a surgery to remove the left vulva due to cancer. Due to a surgical error, the patient had the right side of the vulva removed by surgeons (PSNet, 2017). The wrong-part surgery refers to a surgical procedure that takes place in the proper region, but at the wrong anatomical part. For example, operating on the incorrect level of the spine. Personnel involved in the care of the surgery patient should
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This incidence approximately occurs at a rate of one in 30,000 to less than one in 100,000 surgeries. The actual incidence might be even higher due to a reporting bias. The World Health Organization (WHO) created the safe surgery checklist in the year 2008. The aim of the safe surgery checklist was to diminish mistakes in patient care and adverse events. The WHO’s patient safety checklist has made recommendations to improve teamwork and communication (Thurnherr et al., 2017). The Universal Protocol also highlights the use of timeout before all procedures related to surgery and any invasive procedures. The concept of the surgical timeout is to set aside a planned time meeting in order to review crucial aspects of the procedure with all involved personnel. It helps in developing better communication in the operating room and lowers the risk of wrong site patient surgery (PSNet,
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.
A do not resuscitate order for patients who have emergency surgery is an “independent risk factor for poor surgical outcome and postoperative mortality” (Kelley , 2014 pg 1 para 3) and the probability of returning patients to their previous level of functioning is higher for CPR performed during the peri-operative period (Kelley , 2014).
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.
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/
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
There are a few types of medical errors discussed in Patient Safety Principles & Practice. One of them is an error of execution. An error of execution is when a correct action does not proceed as intended. It is a failure of a planned action to be completed as first intended. It occurs unintentionally during an automatic performance of patient care. This error is almost always observable at the patient and caregiver interface.
Ignatavicius, D. D., & Workman, M. L. (2013). Care of Intraoperative Patients. Medical-surgical nursing: patient-centered collaborative care (7th ed.). St. Louis: Elsevier.
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.
The PICOT model creates a template for clinicians that allow them to break down clinical questions related to a specific population. With this model, clinicians find information via online databases and journals to gather accurate data. Often, health care providers have the capacity and interest in formulating a question, however they lack research strategy (Riva, Malik, Burnie, Endicott & Busse, 2012). The PICOT model helps bridge the gap between questions and answers. A concern of mine in health care deals with mistakes made in the operating room. The proposed research question is “Does the implementation of the World Health Organization’s Surgical Safety Checklist, in its entirety, reduce the rate of surgical mistakes and increase positive results compared to surgeries that do not follow all aspects of the surgical safety checklist; especially in lower income countries or emergency surgery situations where time is not
Wu, A. W. (2011). The value of close calls in improving patient safety: Learning how to avoid
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).
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
Whether you are coming in to sit and wait for someone or you are the one who is having a procedure done safety and quality in any department of health is very important. Patient safety and quality of hospital care can affect hospital ratings.