Placing patient safety first

AORN Journal,  April, 2008  by Suzanne C. Beyea

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This column is the fourth in a series focusing on safety goals for perioperative nurses. This month s column addresses the important goal of placing patient safety first every day. Achieving this goal may present one of the greatest challenges for clinicians and health care organizations. It is particularly challenging in perioperative settings because there is pressure to maintain patient flow, and sometimes it may appear that procedural volume takes priority over best practices. With every activity and intervention, however, clinicians need to question whether patient safety is being placed first and whether the procedure is being performed in the safest manner.

In clinical environments, the importance of making patient safety the top priority cannot be overstated. For example, if a nurse does not review the preoperative checklist because there is a backlog of patients, patient safety details easily can be overlooked, including whether the surgical permit accurately lists the surgical site or side. The failure of the nurse to perform a thorough review could result in a surgical site error in which other members of the health care team could easily become complicit. This is especially true if other clinicians fail to thoroughly review the surgical permit or medical record because they assume that the nurse already conducted a complete review of the patient's paperwork.

SYSTEM REDUNDANCIES

A number of principles guide and support safe patient care within clinical settings. One of these relates to system redundancies that are put in place to pre vent errors. Numerous system redundancies have been set up in most health care environments. For example, checking a patient's identity before administering medications or other treatments is a system redundancy designed to prevent the misidentification of patients. This fairly routine and basic task provides an instrumental safety intervention. Another system redundancy is conducting independent double checks of high-risk medications. Many nurses learned to conduct double checks with another nurse before administering any of these medications. The purpose of the independent double check is that each nurse verifies the order, conducts the necessary calculations, and determines the accuracy of the medication preparation.

For example, an order may require a nurse to ad minister 4,000 units of heparin to a patient for prevention of deep vein thrombosis. The nurse who prepares the medication might say to another nurse, "This syringe contains heparin 4,000 units, which is 0.8 mL of a 1 mL vial of 5,000 units." The second nurse independently checks the order, conducts the necessary calculations, and inspects the medication vial, discovering that the vial actually contains 25,000 units of heparin. In this way, the second nurse identifies the error that was made by the first nurse, and the error can be corrected before it reaches the patient.

Independent checks provide an opportunity to prevent an error from passing from one step of the process to the next, or through the "holes" in Reason's Swiss Cheese Model of System Failure. (1) This model depicts how errors, when they occur, are able to reach the patient because clinicians or processes fail to prevent or detect them. According to this model, when systems or clinicians are able to "block the holes," harmful errors are prevented.

A good example of system redundancy that is used to block the holes throughout the surgical patient preparation process is a facility-wide focus on correct site surgery. From the time of preparing and signing the surgical permit, efforts made by the surgeon, staff members, and patient (eg, the patient and surgeon marking the site, the patient's verification that the correct site is recorded on the permit, the surgical time out) help ensure that wrong site surgery is avoided. Members of the health care team, including the staff member who schedules the surgery and the team members who conduct the final time out prior to making the incision, continue to block potential errors from reaching the patient. If health care clinicians stop performing these tasks, many more errors will occur, and patients will be harmed.

ACTIVELY ENSURING PATIENT SAFETY

Unfortunately, some clinicians fail to perform a safety check or task because of time pressures or other clinical demands. According to the Joint Commission, wrong site surgical errors continue to occur. (2) There are a variety of reasons why they occur, including

* an increase in the number of emergent procedures,

* communication problems, and

* the failure to follow correct site procedures. (3)

Perhaps some of these errors occur because a nurse or another health care clinician assumes that someone else has addressed a problem or concern. Other patient safety problems may occur because clinicians believe that a certain intervention is not crucial to the overall safety and well-being of the patient. For example, an increase in health care-acquired infection rates may indicate that clinicians have stopped washing their hands as frequently as they should.