Safety & Quality in the Preop/PACU setting 1:15-2:15.

Safety & Quality in the Preop/PACU setting

1:15-2:15

Objectives

• Describe quality improvement and patient safety

goals.• Identify safety practices that affect the patient and

the nurse in the perianesthesia arena.

Safety Culture Best practices and best outcomes are important in today's healthcare environment. The perianesthesia environment of care is constantly challenged with:

Introduction of new technologies, Improved medicationsAdvances in surgical and nonsurgical procedures

Fast turnover Increasing volume High-acuity patients.

The integration of principles of safety and evidence-based principles is a core value of perianesthesia practice.

• Joint Commission 2012 Patient Safety Goals – Promote improvement– Highlight problematic areas of health care – describe

evidence & expert based solutions– System wide solutions– Guided by sentinel Event Advisory Group• Nationally recognized experts with hands-on

experience in health care organizations• Annually recommend core and specific NPSG

• Revised for 2012

National PATIENT SAFETY Goals (NPSG) Effective 1/1/2013

• NPSG.01.01.01 Use at least 2 patient identifiers when providing care, treatment, and services.• 1. Use at least 2 patient identifiers when administering

medications, blood, or blood components; when collecting blood samples and other specimens for clinical testing; and when providing treatments or procedures. Patient’s room or physical location is Not used as an identifier

• 2. Label containers used for blood and other specimens in the presence of the patient.

Goal 1- Improve the accuracy of patient identification

Goal 1- Improve the accuracy of patient identification

• NPSG.01.03.01 Eliminate transfusion errors related to patient misidentification.– 1. Before initiating a blood or blood component transfusion:

• Match the blood or blood component to the order..• Match the patient to the blood or blood component.• Use a 2 person verification process or a one person verication

process accompanied by automated identification technology, such as bar coding.

– 2. When using a 2 person verification process; 1 conducting the ID verification is the qualified transfusionist who will administer the blood or blood component to the patient

– 3. When using a 2-person verification process, the second individual conducting the ID verification is qualified to participate in the process, as determined by the hospital.

• NPSG.02.03.01 Report critical results of tests and diagnostic procedures on a timely basis. – 1. Develop written procedures for managing the

critical results of tests and diagnostic procedures:– 2. Implement the procedures for managing the

critical results of tests and diagnostic procedures– 3. Evaluate the timeliness of reporting the critical

results of tests and diagnostic procedures

Goal 2 – Improve the effectiveness of communication among caregivers.

• NPSG.03.04.01 Label all medications, medication containers and other solutions on and off the sterile field in perioperative and other procedure settings.

• 1. In periop/procedural settings both on and off the sterile field label meds and solutions that are not immediately administered, even if only 1 med is used.

• 2. labeling occurs when any medication or solution is transferred from the original package to another container.

• 3. medication or solution labels include the following:– Med name; Strength, Quantity; Diluent & volume;

Expiration date when not used within 24 hours; Expiration time when occurs in less than 24 hours.

Goal 3 – Improve the safety of using medications


• NPSG.03.04.01• 4. Verify all meds or solution labels both verbally & visually.

Verification is done by 2 individuals qualified to participate in the procedure..

• 5. Label each med or solution as it is prepared• 6. Immediately discard any med or solution found

unlabeled.• 7. remove all labeled containers on the sterile field and

discard their contents at conclusion of procedure• 8. All meds & solutions both on and off the sterile field and

their labels are reviewed by entering & exiting staff responsible for the management of meds


• NPSG.03.05.01 Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.

• 1. use only unit-dose products, prefilled syringes, or premixed bags when these products used

• 2. use approved protocols• 3. Assess patient’s baseline coag status before

starting on warfarin


• 4. use authoritative resources to manage potential food & drug interactions for patients receiving warfarin

• 5. When heparin is administered, use programmable pumps.

• 6. A written policy addresses baseline and ongoing lab tests

• 7. Provide education regarding anticoagulant therapy and importance of follow-up monitoring & compliance

• 8. evaluate anticoag safety practices.


• NPSG.03.06.01 Maintain and communicate accurate patient medication information.

• 1. Obtain information of meds patient taking• 2. Define the types of medication information to be collected in

non-4 hour setting• 3. Compare the med info brought to the hospital with meds

ordered in the hospital for pt.• 4. Provide the patient with written info on the meds they should

be taking when discharged from the facility.• 5. Explain the importance of managing med information to the

patient when discharged from the facility.

• NPSG.07.01.01: Comply with the current CDC hand hygiene guidelines or the WHO hand hygiene guidelines 1. Implement a program that follows either the CDC or the WHO hand hygiene guidelines2. Set goals for improving compliance with hand hygiene guidelines3. Improve compliance with hand hygiene guidelines based on established goals.

Goal 7 – Reduce the risk of health care- associated Infections.


• NPSG.07.03.01: Implement evidence-based practices to prevent healthcare-associated infections due to multidrug-resistant organisms in acute care hospitals.

• 1. Conduct periodic risk assessments for multidrug resistant organism acquisition and transmission

• 2. Based on results of risk assessment, educate staff about health care – associated infections, multidrug resistant organisms & prevention strategies at hire and annually thereafter.


• 3. Educate patients and their families• 4. Implement a surveillance program for

multidrug-resistant organisms based on the risk assessment

• 5. Measure and monitor multidrug-resistant organism prevention processes and outcomes…

• 6. Provide multidrug-resistant organisms process & outcome data to key stakeholders including leaders, LIP, nursing staff & other clinicians


• 7. implement policies and procedures aimed at reducing the risk of transmitting multidrug resistant organisms…..

• 8. when indicated by the risk assessment, implement a lab based alert system that identifies new patients with multidrug-resistant organisms…..

• 9. When indicated by the risk assessment, implement an alert system that identifies readmitted or transferred patients who are know to be positive for multidrug-resistant organisms.


• NPSG.07.04.01 Implement evidence based practices to prevent central line-associated bloodstream infections.

• 1. Educate staff and LIP who are involved in managing central lines about central lines- associated bloodstream infections and the importance of prevention

• 2. Prior to insertion of a Central venous cath, educate patient and as needed their families about central line associated bloodstream infection prevention


• 3. Implement policies and practices aimed at reducing the risk of central line – associated blood stream infections.

• 4. Conduct periodic risk assessments for central line-associated blood stream infections, monitor compliance with EBP, and evaluate the effectives of prevention efforts

• 5. Provide central line – associated bloodstream infection rate data and prevention outcome measures to key stakeholders…


• 6. Use a catheter checklist 7 standardized protocol for CVP insertion.

• 7. Perform hand hygiene prior to cath insertion/manipulation.

• 8. For adults, do not insert catheters into femoral vein unless no other site available.

• 9. Use a standardized supply cart that contains all necessary components for insertion.


• 10. Use a standardized protocol for sterile barrier precautions during Central venous cath insertion.

• 11. Use an antiseptic for skin prep during CVP insertion that is cited in scientific literature and endorsed by professional organizations.

• 12. Use a standardized protocol to disinfect catheter hubs and injection ports before accessing the ports.

• 13. Evaluate all CVP catheters routinely and remove nonessential catheters.


• NPSG.07.05.01 Implement EBP for preventing surgical site infections

• 1. Educate staff and LIP involved in surgical procedures about surgical site infections and the importance of prevention. Educate on hire and annually thereafter.

• 2. Educate patients & families as needed• 3. Implement P&P aimed at reducing the risk

of surgical site infections…


• 4. As part of the effort to reduce surgical site infections (SSI) – Conduct periodic risk assessments for SSI in a time frame

determined by the hospital.– Select surgical site infection measures using best

practices or EBP guidelines– Monitor compliance with best practices or EBP– Evaluate the effectives of prevention efforts

• 5. Measure SSI rates for the first 30 days following procedures that do not involve inserting implantable devices

• 6. Provide process and outcome measure results to key stakeholders


• 7. Administer antimicrobial agents for prophylaxis for a particular disease/procedure according to methods cited in scientific literature or endorsed by professional organizations.

• 8. When hair removal is necessary, use a method that is cited in scientific literature or endorsed by professional organizations.


• NPSG.O7.06.01 Implement EBP to prevent indwelling catheter-associated urinary tract infections (CAUTI). This is not applicable to ped patients.

• 1. Insert indwelling urinary catheters according to established EBP that address– Limiting use and duration to situations necessary for

patients– Using aseptic techniques for site prep, equipment and

supplies


• 2. Manage indwelling catheters according to established EBP that address:– Securing catheters for unobstructed urine flow

and drainage.– Maintaining sterility of urine collection system.– Replacing the urine collection system when

required– Collecting urine samples


• 3. Measure and monitor cath-associated urinary tract infection prevention processes and outcomes in high volume areas by doing the following: – Select measures using EBP/best practices–Monitor compliance with EBP/best practices– Evaluating the effectiveness of prevention

efforts

• NPSG.15.01.01 Identify patients at risk for suicide. {Applies to psych hospitals & those patients being treated for emotional or behavioral disorders in general hospitals}– 1. Conduct a risk assessment that identifies patient

characteristics and environmental features that may increase or decrease risk for suicide.

– 2. Assess patient’s immediate safety needs– 3. When a patient at risk for suicide leaves the care of

the hospital, provide suicide prevention information

Goal 15- The hospital identifies safety risks inherent in its patient population

• UP.01.01.01 ®Conduct a pre-procedure verification process– 1. Implement a preprocedure process to verify

the correct procedure, for the correct patient at the correct site.

– 2. Identify the items that must be available for the procedure and use a standardized list to verify their availability

– 3. Match the items that are to be available in the procedure area to the patient

U.P. The organization meets the expectations of the Universal Protocol


UP.01.02.01 Mark the procedure site1. Identify those procedures that require marking

of the incision or insertion site. At a minimum, sites are marked when there is more than one possible location.

2. Mark the procedure site before the procedure is performed and, if possible, with the patient involved.

3. The procedure is marked by a LIP who is accountable for the procedure & will be present when the procedure is performed.


• 4. The method of marking the site & the type of mark is unambiguous and is used consistently throughout the hospital.

• 5. A written, alternative process is in place for patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site. ( mucosal surfaces, perineum)


• UP.01.03.01 A time-out is performed before the procedure.– 1. Conduct a time-out immediately before starting the

invasive procedure or making the incision.– 2. The time-out has the following characteristics:• Standardized as defined by the hospital• Initiated by a designated member of the team.• Involves the immediate members of the team: – Individual doing the procedure, -Anesthesia–Circulating nurse, -Operating room tech– Participants involved in the procedure from the

beginning


• 3. When 2 or more procedures are being performed on the same patient, and the person performing the procedure changes, perform a Time Out before each procedure is initiated.

• 4. During the Time Out, the team members agree at a minimum, on the following– Correct patient identity; Correct site; Procedure to be

done.• 5. Document the completion of the Time Out

www.jointcommision.org

http://www.jointcommision.org/

QUALITY IMPROVEMENT

• Formal approach to analysis of performance and systematic efforts to improve

• Ongoing effort to make things better.

Surgical Care Improvement Project (SCIP)

• Large national partnership dedicated to reducing the number of preventable surgical complications

• A national campaign was launched to substantially reduce surgical mortality and morbidity through collaborative efforts.

• Steps that can be taken to lower the number of surgical problems.

SCIP: Infection• 1. Prophylactic antibiotic received within one hour prior to

surgical incision• 2. Prophylactic antibiotic selection for surgical patients• 3. Prophylactic antibiotic discontinued within 24 hours

after surgery end time. (48 hours for cardiac patients)• 4. Cardiac Surgery patients with controlled 6AM postoperative

serum glucose (200 mg/dL)• 6. Surgical patients with appropriate hair removal• 7. Colorectal surgical patients with immediate postoperative

normothermia.• 9. Urinary catheter removed on POD 1 or POD 2 with day of

surgery being day 0.• 10. Surgery patients with perioperative temperature

management.

SCIP: Cardiovascular

• 2. Surgical patients on a beta-blocker prior to arrival that received a beta blocker during the perioperative period.

SCIP: Thromboembolic

• VTE 1: Surgical patients with recommended venous thromboembolism prophylaxis ordered.

• VTE 2: Surgery patients who received appropriate venous Thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery.

• Violence in the Workplace• Shift work & Long hours• Musculoskeletal Injuries• Needle sticks• Chemical Occupational Exposures• Mental Health Effects of Nursing work

Staff Safety

• OSH Act of 1970 mandates employers have a duty to provide workplace free from recognized hazards likely to cause death or serious harm

• 25/10,000 FT nurses were assaulted in 2000

Physician (Patient ) shoots nurse in Denver hospital

Violence in the Workplace

What is Horizontal Violence?

• Horizontal violence or lateral violence can be described as overt or covert aggressive and destructive behavior of nurses against each other.

• It’s more than ‘Nurses eat their young’….

Workplace Violence

• Intimidation– Stalking– Actions to frighten &

coerce

• Threats– Expression of intent to

cause physical or mental harm

• Property damage– Intentional damage to

property

• Physical Attacks– Unwanted hostile

physical contact– Hitting– Fighting– Pushing– Shoving– Throwing objects

• Sexual harrassment

Sexual HarrassmentUnwelcome Advances

Requests for sexual favorsVerbal or physical conduct of a sexual nature

When submission to or rejection of this conduct explicitly or implicitly affects:

-person’s work or educational performance -creates an intimidating, hostile or offensive working or

learning environment

Types of Behaviors

Types of Behaviors

Types of Behaviors• Backstabbing• Disrespectful behaviors• Failure to respect privacy• Belittling remarks• Persistent criticism

• Intitmidation• Humiliation• False accusations• Social isolation• Unreasonable workloads

Risk Factors for Violence• Working directly with

volatile people• Transporting patients• Long waits for service• Overcrowded,

uncomfortable waiting rooms

• Drug & alcohol abuse• Access to firearms• Unrestricted movement

of the public• Poor environmental

design

• Working when under staffed– Meal times– Visiting hours– Call hours

• Working alone• Lack of staff training &

policies for managing crises

• Poorly lit corridors, parking lots and other areas

• Inadequate security

Alternative terms

• Mobbing• Bullying• Lateral Violence• Nurse Hazing• Horizontal Violence• Verbal Abuse• Workplace Violence• Workplace Aggression

Incidence

• Scandinavian Countries – 1 to 5 %

• UK and US – 10 to 38 %

• Australia – 50 to 57%

• Turkey – 86.5%

Causes• Apathy towards ‘bad’ behaviors– Desensitized– “It is what it is.”

• Enabling– “That’s just the way she/he is”– “She/he is just having a bad day”

• Complacency– “I don’t have time to deal with it”– “I don’t want to get involved”– “A silent witness”

• Fear of retaliation– “If I say something, I’ll be the next target”

Causes

• Subservient role to MDs (oppressed-group model = perceived lack of power)– Nursing, under

Florence Nightingale, developed as a very hierarchical system where submission was ‘expected, encouraged, indeed, demanded’.

• Low self esteem• Leadership too

authoritarian/too ‘laissez-faire’

• Stressful work environment – volatility– Shrinking resources– Downsizing– Restructuring

• Demanding work

Workplace Violence

• Nurses are responsible for reporting any disruptive behavior in the workplace to the management team

• Leaders and educators must educate and mentor nurses empowering them to manage perceived workplace violence

• Leaders must develop guidelines within their own settings to incorporate this position statement

• Position Statement:-Violence or threat of such must NOT be tolerated

-Violence directed toward the Periop team interferes with the provision of safe competent and ethical care

-Responsibility for providing an environment free of violence is shared among the org, members of the periop team, patients and their families

(CSPS)Council on Surgical & Perioperative Safety

Position Statement (cont) -Organizations should implement policies that support

violence-free workplaces-The confidentiality of the individuals involved should be taken into consideration but not interfere with an aggressive approach to the issue

(CSPS)Council on Surgical & Perioperative Safety

• Musculoskeletal Injuries• Needle sticks• Chemical Occupational Exposures• Mental Health Effects of Nursing work

Shift work & Long hours

• Health care workers at high risk for Back, neck and upper extremity injuries

• Lead to sick days, disability and turnover• Physical/postural risk factors– Static postures maintaining tension on instruments in

OR- Head, neck, back stress– Lifting & stooping associated with arm and neck

complaints– Pushing & Pulling motions associated with shoulder

complaints

Musculoskeletal Injuries

• Impact of Work schedules– Long hours leads to musculoskeletal injuries:• Extended exposure to physical/postural risk• Insufficient recovery time

–Rotating shifts• Inadequate sleep


• Evidenced Based Interventions for MSD– Patient handling equipment/devices (height

adjusted electric beds, patient lifts, bed repositioners)

– No-lift policies (Minimize manual patient handling)– Training on proper use of patient handling

equipment/devices– Patient lift teams (2 physically fit people

competent in lifting techniques)


• In a 2008 ANA survey 2/3 of 700 nurses surveyed say needlesticks and bloodborne infections are major concerns

• 1/2 go unreported• 64% involve nurses• Occupation acquired – Hepatitis B: 6-30% – Vaccine: HBV– Hepatitis C: 0.4-1.8%: – No vaccine– HIV: 0.3%

• Safer needle devices

Needlesticks

• Hazardous chemical exposures occur in a variety of forms–Aerosols–Gases– Skin contaminants

• Substances used can cause asthma or trigger asthma attacks

Chemical Occupational Exposures

• Anesthetic Gas• Harmful effects– Hematological alterations– Neurological alterations• Decreases in mental performance• Decreases in Audiovisual ability• Decreases in manual dexterity

– Reproductive abnormalities• Spontaneous abortion• Birth defects• Reduced fertility

Nitrous Oxide

Krajewski W, M. Kucharska, Wesolowski et al. Occupational exposure to nitrous Oxide. AORN Journal September 2008 pp. 466-467

• Occupational exposure limit in the air should not exceed 25 ppm in USA

• Should have no greater than 2ppm of volatile hydrogenated hydrocarbon when combined with Nitrous Oxide

Nitrous Oxide

Krajewski W, M. Kucharska, Wesolowski et al. Occupational exposure to nitrous Oxide. AORN Journal September 2008 pp. 466-467

• Latex exposure from natural proteins in rubber latex

• Symptoms:– Contact dermatitis– Asthma– Anaphylaxis

• ANA position statement: Use of low-allergen powder free gloves and remove latex containing products from worksite

Latex Exposure

Mental Health Effects of Nursing Work with job strain

Major Morbidities

• Tension• Anger• Anxiety• Depressed

mood•Mental fatigue • sleep

disturbance

• Depression• Anxiety

disorders• Psychotic

disorders

ASPAN Position Statement on Fatigue

• 2010-2012 PeriAnesthesia Nursing Standards and Practice Recommendations Statement– Position Statement 4A: ASPAN Fatigue Evaluation Check List– ASPAN recognizes fatigue among nurses is a potentially

dangerous situation.– Factors related to nurse fatigue include• Professional scheduling factors (on call; Mandatory OT)• Personal factors (age, OT, work more than 1 job)• Job performance (fall asleep, struggle to stay awake)• Nurse health (Musculoskeletal injury, needle stick)

Sleep deprivation

• Research has shown that a person can recover from sleep deprivation after 2 consecutive nights of adequate sleep (6-8 hours), even after several days of working 12 hour shifts.

Staff Safety

• Violence in the workplace• Shift work & long hours• Musculoskeletal injuries• Needle sticks• Chemical occupational exposures• Mental health effects of nursing work

Handoffs – Transfer of Care

• Transfer of patient information and responsibility between health care providers

• Handoffs occur at every shift change and whenever a patient changes locations

Handover

• Communication that related the process of passing patient specific information from one caregiver to another; from one team of caregivers to the next, or from caregivers to the patient and family for the purpose of ensuring patient care continuity and safety

10 Most Common Hospital Patient Hand-Offs

• Ambulance to ED• ED to inpatient unit• ED to test (eg,

radiology)• Direct admit from

clinic• During procedures• During surgery

• After surgery• From inpatient unit

to inpatient test• Nursing shift

change• MD to MD report

Communication Breakdown

Studies reveal that a majority of avoidable adverse events are due to the lack of effective communication…– Lost information– Misinterpretation– Misdirected or missed actions

...this has spurred a national movement to improve communication during handoffs and patient care transitions

Poor Communication

• “…several studies have shown that twice as many errors occur due to poor communication than to incompetence.

• An astounding 26% of medical errors can be attributed to poor communication between caregivers.”

Handoffs

• “In other contexts, such as air traffic control, handoffs are structured and practiced repeatedly to ensure successful transitions from one person to another, yet most healthcare organizations still rely primarily on ad hoc, loosely managed exchanges between care team members.”

http://www.mercurymd.com/en/Solutions/PatientHandoff/

Communication Breakdown

• Operative/Postop events

• Perinatal deaths & injuries

• Restraint deaths • Ventilator events • Wrong-site surgery

• Anesthesia related events

• Delays in treatment • Infection associated

events • Maternal deaths &

injuries • Medication errors


• Joint Commission Requirements2008 National Patient Safety Goal– Implement a standardized approach to

“hand off” communications, including an opportunity to ask and respond to questions

• Written or taped reports between shifts - do not allow for questions to be asked

TJC “Attributes” of Effective Hand-Off Communications

• Hand offs are interactive communications allowing the opportunity for questioning between the giver and receiver of patient/client/resident information

• Hand offs include up-to-date information regarding the patient’s/client’s/resident’s care, treatment and services, condition, and any recent or anticipated changes


• Interruptions are limited during hand offs to minimize the possibility that information would fail to be conveyed or would be forgotten

• Hand offs require a process for verification of the received information, including repeat-back or read-back, as appropriate


• The receiver of the hand off information has an opportunity to review relevant patient/client/resident historical data, which may include previous care, treatment, and services

Verbal or Face-to-Face Report

• Is a verbal or face-to-face interaction between sender and receiver required?–Requirement: there must be “an

opportunity to ask and respond to questions”– This is an opportunity - need to have

standardized processes in place to assure communication occurs–How do you provide for questions to asked,

answered?

ASPAN Safe Transfer of Care

• The receiving unit will be notified of impending transfer–How do you do this?

• The receiving licensed nurse will be given a complete report before or at the time of transfer–How is this accomplished?

Safe Transfer

• Opportunity was present for questioning between the giver and receiver of the patient– Follows NPSG statement–What does this look like where you are?

Tools to Use for Better Handoffs

• I PASS THE BATON (AHRQ)• Ticket To Ride• Nursing Knowledge Exchange (Kaiser Permanente)• SBAR –(Situation-Background-Assessment,

Recommendations)• SHARED (Standardized Critical Content-Hardware

within system- Allow opportunities to Ask ?, Reinforce Quality & Measurement)

• SHAR-Q- (Situation-History-Assessment-Recommendation-??)

HANDOFF• H – Hello• A – Assessment• N – Necessary patient information• D – Danger of Risks• O – Occurrernce• F – Framework• F- Future Recommendation• S-Seek ????

Keys to Successful Handoffs

• Communication– Interdisciplinary– Multidisciplinary

• Tools– Develop standardized tools to provide consistent

information across all areas• Provide means for feedback and process

improvement


• What methods are working in your practice environment?

• What improvements would you recommend?

• What data supports your process for handoffs?

Let’s be Safe

[email protected]

mailto:[email protected]

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