Safety highlights from conference

AORN Journal,  Nov, 2003  

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One of the main goals of the Multispecialty Conference, Sept 25 to 28, 2003, in Denver, was to increase understanding of perioperative patient safety issues. Many of the sessions were directly or indirectly related to patient safety topics. The following sessions are just a few that directly addressed safety issues. Unfortunately, we do not have room to include all information from all of the sessions.

Defining a culture of safety

Karlene Kerfoot, RN, PhD, CNAA, FAAN, Clarian Health, Indianapolis

Key Points:

* Adopt a high-reliability organization mindset and abandon a mindset that says policies and procedures can solve problems in the health care setting.

* Facilities have to take a proactive approach that plugs up the holes in the system, but they first have to know about the holes.

* Managers and leaders should "stalk" the problems and the near misses, so they can "vaccinate the system against the big problems."

* Aggressively pursue even the most minor problems.

* Intensively train during routine operations, drills, and simulations to be prepared.

* Examine safety and reliability for all the organization's activities.

* In the OR, the unexpected happens every day. Actively plan for the unexpected.

Surgical site infections (SSIs)

Carolyn L. Twomey, RN, BSN, Richmond, Va

Key Points:

* Worldwide, 22 million people died from infections this year alone.

* To decrease the risk of SSIs:

* use supplemental oxygen intraoperatively and postoperatively,

* prevent hypothermia intraoperatively,

* use antibiotic irrigation,

* provide nutritional support preoperatively and postoperatively, and

* protect tissue with gentle manipulation during surgery.

* Double gloving is a priority--single gloves have more than twice the puncture rate of double gloves.

Teamwork, collaboration in the OR

Michael Leonard, MD, Colorado Permanente Medical Group, Evergreen, Colo

Key Points:

* Communication and teamwork are key to patient safety.

* The health care culture today rewards perfection and frowns on error.

* Administrators believe fixing the person rather than the underlying cause will make the problem go away.

* Error is inevitable because of human limitations.

* The majority of problems in the OR are related to communication failure.

* Start surgical procedures with briefings, where everyone's contribution and purpose is recognized.

* Acknowledge team members by name.

* Be assertive in pointing out errors or practices that can lead to errors.

Error potential--Error prevention

Jeannie Botsford, RN, MS, CNOR, surgical consulting specialist, Costa Mesa, Calif.

Key Points:

* Failure mode effects analysis should be applied to the health care environment to improve safety.

* AORN's Patient Safety First voluntary reporting site allows nurses to report near misses, which helps all nurses learn from one another.

* Policies must define clear, accurate, complete, and legible order to ensure safe medication management.

* Universal protocols must be established within and between facilities in a community to ensure correct site surgery that clearly establish guidelines for right/left distinction, multiple structures, and multiple levels.

COPYRIGHT 2003 Association of Operating Room Nurses, Inc.
COPYRIGHT 2003 Gale Group