Management

Patient Safety in the Operating Room

A cultural assessment may be one of the best ways to measure OR quality and identify areas for improvement

Patient safety is improving the system by learning where people fail and not by holding people accountable for failure ----- John R Clarke

"We should have reliable robust standardised operations in which error is trapped and correction is done within the system with Root Cause Analysis" - Dr Reena Kumar Department of Hospital Administration Officer In-charge Operation Theatres Sir Ganga Ram Hospital, New Delhi

In the decade since the Institute of Medicine's landmark 'To Err is Human' report, which estimated that up to 98,000 people a year die of medical errors, many hospitals have embraced a 'no blame' model- Instead of focusing on a single individual to blame for a mistake, they've tried to set up systems to prevent mistakes, catch them before they cause harm, or mitigate harm from errors that do reach patients.

'The High 5s'

World Alliance for Patient Safety has launched 'Safety in Action - High 5s' which are standard operating protocols.

• Managing concentrated injectable medicines.
• Assuring medication accuracy at transitions in care.
• Communication during patient care handovers.
• Performance of correct procedure at correct body site.
• Improved hand hygiene to prevent health care associated infections.

The Mission of the 'High 5s Project' is to facilitate implementation and evaluation of standardised patient safety solutions within a global learning community to achieve measurable, significant, and sustained reductions in high risk patient safety problems.

The first challenge of World Health Alliance for Patient Safety focuses on the 'Clean care is Safer Care' which focuses on the prevention of health care associated infections while the second challenge 'Safe Surgery Saves Lives' focuses on the prevention of complications resulting from surgery.

Patient safety in the operating room has long been a concern for hospitals. Numerous initiatives to improve OR care have had some impact, but problems persist. Wrong-site surgery, for example, has received a great deal of focus. The Joint Commission implemented a universal protocol in July 2004 that requires a pre-operative verification process, the marking of the operative site and taking a 'time-out' immediately before starting the procedure, among other things. But providers say that compliance is difficult and the number of reported incidents of wrong-site surgery has increased. According to patient safety experts, one of the biggest barriers to improving patient safety in the OR is the working culture. Today, it's imperative that everyone works together. Making that change, however, is not easy. 'Surgeons see patient safety as a hospital issue, not a surgeon issue' according to Dr Peter Angood, Co-director and Vice President & Chief Patient Safety Officer for the Joint Commission. To overcome these problems, hospitals must first assess the culture of the OR, address top priorities and build teamwork among clinicians and supporting departments.

Assessing Your OR Culture

As with other safety initiatives, understanding the culture of the operating room is crucial to success. A cultural assessment may be one of the best ways to measure OR quality and identify areas for improvement. This gatefold examines the risks associated with the OR and provides examples of how organisations can identify and address cultural issues.

'At Risk Behaviour' in OR

This is a major contributor to adverse events/ errors in OT as for instance, not checking equipment before use, surgeon entering after pre-op preparation and draping, surgeon running two ORs, multi-tasking from OR, relying on memory about the pathology, unlabelled clear filled syringes/ biopsy samples, continuing to close the operating site during sponge search etc. Communication failure is the root cause in OR sentinel events, wrong site surgery and other errors that occur in OR. Effective communication should be primary component of any team-based activity, particularly surgical procedures.

Toolkit for Safe Surgery

2007 National Patient Safety Goals provide guidelines for detailed implementation requirements, exemptions and adaptations for special situations which include:

Sign in - Pre-operative verification process: Verification of the correct person, procedure and site, relevant documents, images, implants, special equipment. Marking the operation site and final verification of the site mark must take place during the 'timeout'.

'Time out' as per universal protocol (wrong site, wrong procedure, wrong person surgery can be prevented immediately before starting the procedure). It must be conducted in the location where the procedure will be done, just before starting the procedure. It must involve the entire operative team, use active communication, be briefly documented, such as checklist which must include:

• Correct patient identity.
• Correct side and site.
• Agreement on the procedure to be done.
• Correct patient position.
• Availability of correct implants and any special equipment or special requirements.

WHO study shows use of checklist significantly improves patient safety. The organisation should have processes and systems in place for reconciling differences in staff responses during the 'time out'.

Sign out and review of critical information:

• Are the sponge counts correct?
• Are the specimen labeled properly?
• Post-operative diagnosis.
• Verification of procedure completed.
• Any special postoperative considerations?
• Debriefing at the end of surgery with the operating team can lead to- to
• Change in process, more effective future performance.
• Revised or new procedures.
• Improved team work.
• Staff satisfaction.

Instead of the current adhoc system in which error identified by an individual is corrected with workaround and change in policy, leading to complexity and the weakness still persists, we should have reliable robust standardised operations in which error is trapped and correction is done within the system with Root Cause Analysis (RCA). Ongoing initiatives are being taken at national and international levels to ensure patient safety. The best practices should be uniformly adopted by all hospitals.

National Accreditation Board for Hospitals and Health Care providers (NABH), a constituent board of Quality Council of India, provides framework for quality assurance and quality improvements. The standards focus on patient safety and quality of patient care.

National Patient Safety Policy was launched in India by Health Minister Ghulam Nabi Azad at All India Institute of Medical Sciences in collaboration with World Health Organisation (WHO) and the India Clinical Epidemiology Network (INCLEN). Patient safety initiative will enable a safer healthcare environment for patients.

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