Designing and implementing a patient safety program for the OR - Patient Safety First

AORN Journal,  Sept, 2002  by Janet O. Bower

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Fortunately, this situation was reversible, but the patient did experience symptoms and had to undergo a second surgery. Staff members felt remorse and embarrassment about the error. This incident, which occurred in late summer of 2000, became a catalyst for the creation and implementation of a formal patient safety quality improvement program for the OR.

At that time, issues such as retained objects, incorrect counts, needle sticks, and patient injuries were reported to UWMC's risk management department, but there was no formal process to inform staff members of error trends or to ensure implementation of improvement projects as a result of near misses or negative outcomes. Process changes were slow and inconsistent. Nurses often learned about events and negative outcomes through gossip, which could be inaccurate.

The anesthesia department at UWMC has a successful risk management/quality improvement program that has been in place for 10 years. The program allows anesthesia care providers to report issues, which then are discussed at weekly peer review meetings. (3) Based on the discussions, improvements are made, education is provided, and information is communicated through clear and appropriate channels. The perioperative nurses saw this program as a model they wished to adopt. (4) With support from their leaders and via a grassroots effort, the nurses were able to design and implement a program that has energized, organized, and improved teamwork and resulted in improved patient outcomes. This article provides an explanation of the frameworks concerning risk management, quality improvement, and OR culture and gives a detailed description of how the UWMC program works.

RISK MANAGEMENT

Risk management primarily is concerned with protecting an institution from financial losses from malpractice claims, as well as protecting professionals from the stress and disruption that result from the litigation process. Providing risk management education to prevent negative outcomes is as important as mitigating activities after an event has occurred. To decrease the possibility of litigation, risk management focuses on maintaining minimum standards. Risk managers want to make sure that the standard of care is followed and that health care providers obtain informed consent, document thoroughly, communicate clearly, and act in compliance with all state and federal laws. (5)

QUALITY IMPROVEMENT

In contrast, quality improvement is concerned with exceeding the standard of care, examining ways to be more efficient, improving satisfaction, and focusing on service. One researcher describes quality improvement as comprising structure, process, and outcomes. (6) Structure refers to the tangible aspects (eg, room layout, surgical instruments, equipment) of the environment in which work is done. Process refers to how the work is done. Is there clear communication? Are policies and procedures being followed? Are health care providers competent and educated? Outcomes refer to the end result for the patient. As the structure and process of care is scrutinized and improved, there should be a measurable improvement in patient outcomes. Examples of success include a decrease in errors, a decrease in the number of patient injuries, an increase in patient and employee satisfaction, and an increase in productivity.

OPERATING ROOM CULTURE

Historically, the culture in the OR is such that surgeons, nurses, and anesthesia care providers downplay or hide mistakes for tear of being punished and experiencing embarrassment. (7) This behavior does nothing to improve patient safety or patient outcomes. Errors usually are a combination of several missed opportunities for prevention. For example, in the case of the retained retractor, neither the nurses nor surgeons noticed that the retractor was left in the patient. Perhaps each was relying on the other to ensure it was removed. Ideally, they all should have taken this responsibility. The surgical team members lacked a system of accounting for instruments, which would have guaranteed that the retractor was removed from the patient before he left the OR.

Decreasing errors requires that systems and processes of care be improved but, more importantly, culture and habits have to change. Better communication; increased vigilance; a culture that accepts that human errors will occur; and a format to discuss errors, near misses, and negative outcomes comfortably are essential. There should be a sense of urgency to protect patients, constant attention to detail, a willingness to learn from other providers, and shared responsibility. Care providers need to search continually for ways to standardize and streamline processes. They need to create a culture that exemplifies safety as everyone's business.

DESlGNING A PROGRAM

The nurses at UWMC used the risk management, quality improvement, and OR culture frame-works to design their patient safety quality improvement program, using the anesthesia department program as a model. To make the venture successful, they needed to involve all staff members and build the program into existing systems. The nurses took an aggressive "bottom-up" approach by acknowledging that care providers are closest to the problems and, therefore, know the best solutions.