Transcript OT Safety Issues - Nurses Rock Society #23

PAPRSB IHS
UBD
PeriOperative Nursing
18th Jan 2011
Objectives

Describe the issues that effect safety in
the OR

Discuss the process for creating an OR
safety program

Identify barriers to the implementation of
a safety program
What Are Adverse Events?
Pt incidents such as:
Patient falls
Medication errors
Surgical / Medical errors
Close calls (intercepted or resulted in no harm)
What Is A Sentinel Event?
-Death or permanent loss of function resulting from a
medication or other Rx error
-Surgery on the wrong patient or body part
-Unintended retained surgical object
-Hemolytic transfusion reaction
-Unanticipated death resulting from an health care-acquired
infection
What Is An Intentional
Unsafe Act?
An adverse event that results from:
 criminal act
 purposefully unsafe act
 alcohol or substance abuse
 impaired provider/staff
 alleged patient abuse
Intentional unsafe acts should be reported to the In Charge
& Management immediately
Intentional Unsafe Acts are investigated by administration
Safe Site Surgery

Performance of:
 The correct procedure;
 On the correct patient;
 On the correct side;
 At the correct site
Safe Site Surgery

Wrong site surgery:
 rare but devastating occurrence
 It occurs when there is no:
○ Easy
○ Systematic
○ Redundant
○ Fail safe
procedure for ensuring that the correct site is being
treated
Wrong Side Surgery: Contributing Factors
Inadequate pt assessment
 Incomplete medical record review
 Poor handwriting
 Reliance on surgeon alone to identify site
 Poor communication among OR team
 Multiple procedures performed on same patient
 Time pressure
 Lack of clear policies

8
Vincent C, et al. BMJ. 2000;320:777-81.
Safe Site Surgery

Pt identification:

Methods needed to ensure the right pt is
being treated

Pt identity is confirmed & communicated
at each transfer

Good oral communication between HCWs
Safe Site Surgery

Procedure & site verification:
 Discussion with pt
 Consult notes
 Consent
 Imaging studies
 Other relevant documentation
 Correct implant if applicable
Safe Site Surgery

Site Marking:
 Universal process
 Involves a member of the surgical team who will be
operating
 Occurs generally prior to transfer to Operating room
 Exceptions
Safe Site Surgery

The “Surgical Pause” or “Time Out”
 ALL members in the room verbally agree to the
procedure being done
 Anyone can challenge prior to the procedure starting
 Method in place to review case if there is not
consensus
Marking

Should be done prior to the OR

Marked on skin (not removable with prep, no
stick-on marking)

Surgeon should sign the site

No extraneous marks

Pt involved
Marking (Exceptions)

Laparoscopic surgery

Midline Surgery

Single orifice surgery

Where decision is made intraop

Spinal Level (intraop marking)
Reduce Healthcare
Acquired Infections (HAIs / HCAIs)
• Comply with current CDC Hand
Hygiene Guidelines.
• Manage unanticipated death or major
permanent loss of function associated
with a HAIs as a sentinel event.
Hand Hygiene Is…
The #1 way to STOP transmission of infection!
Prevent Flu & Pneumonia

Protect yourself…..get immunized!

Protect your patients….
DID YOU KNOW….. With flu you are contagious 24 hours
before you even know you are sick!
DID YOU KNOW….Hospitals with high employee flu
vaccination rates have lower patient mortality!

Protect your families…
home!
don’t take germs
Reduce Risk of Harm From Falls

Assess Fall Risk on admission, each reassessment, & after a fall

Use a Falling Leaf to indicate a patient is a high fall risk

Implement fall prevention devices, alarms & equipment

Correct spills or wet surfaces

Dispose of trash appropriately

Remove or report any trip hazards & environmental hazards immediately

Examine for injury before moving the pt after a fall

Complete incidence report & notify next of kin

Implement additional fall precautions as indicated
Points to Remember about Aseptic Technique

Adherence to the Principles of Aseptic Technique
Reflects One's Surgical Conscience.
1. The patient is the center of the sterile field.
2. Only sterile items are used within the sterile field.
A. Examples of items used.
B. How do we know they are sterile? (Wrapping, label, storage)
3. Sterile persons are gowned &
gloved.
•
A. Keep hands at waist level & in sight at all times.
B. Keep hands away from the face.
C. Never fold hands under arms.
D. Gowns are considered sterile in front from chest to level of
sterile field, & the sleeves from above the elbow to cuffs.
Gloves are sterile.
E. Sit only if sitting for entire procedure.
4. Tables are sterile only at table
level.
A. Anything over the edge is considered unsterile,
such as a suture or the table drape.
B. Use non-perforating device to secure tubing &
cords to prevent them from sliding to the floor.
5. Sterile persons touch only sterile items or
areas; unsterile persons touch only unsterile
items or areas.

A. Sterile team members maintain contact with sterile field by
wearing gloves & gowns.

B. Supplies are brought to sterile team members by the
circulator, who opens wrappers on sterile packages. The
circulator ensures a sterile transfer to the sterile field. Only
sterile items touch sterile surfaces.
6. Unsterile persons avoid reaching over sterile
field; sterile persons avoid leaning over unsterile
area.
•
A. Scrub person sets basins to be filled at edge of table to fill
them.
B. Circulator pours with lip only over basin edge.
C. Scrub person drapes an unsterile table toward self first to
avoid leaning over an unsterile area. Cuff drapes over gloved
h&s.
D. Scrub person st&s back from the unsterile table when
draping it to avoid leaning over an unsterile area.
7. Edges of anything that encloses sterile
contents are considered unsterile.

A. When opening sterile packages, open away from you first.
Secure flaps so they do not dangle.

B. The wrapper is considered sterile to within one inch of the
wrapper.

C. In peel-open packages, the edges where glued, are not
considered sterile.
8. Sterile field is created as close as
possible to time of use.

A. Covering sterile tables is not recommended.
9. Sterile areas are continuously kept in view.

A. Sterility cannot be ensured without direct observation. An
unguarded sterile field should be considered contaminated.
10. Sterile persons keep well within sterile
area.

A. Sterile persons pass each other back to back or front to
front.

B. Sterile person faces a sterile area to pass it.
C. Sterile persons stay within the sterile field. They do not
walk around or go outside the room.

D. Movement is kept to a minimum to avoid contamination of
sterile items or persons.
11. Unsterile persons avoid sterile areas.
•
A. Unsterile persons maintain a distance of at least 1 foot from the
sterile field.
•
B. Unsterile persons face & observe a sterile area when passing it
to be sure they do not touch it.
•
C. Unsterile persons never walk between two sterile fields.
•
D. Circulator restricts to a minimum all activity near the sterile field.
12. Destruction of integrity of microbial
barriers results in contamination.
•
A. Strike through is the soaking through of barrier from sterile to nonsterile or vice versa.
•
B. Sterility is event related.
•
13. Microorganisms must be kept to irreducible minimum.
•
A. Perfect asepsis is an idea. All microorganisms cannot be eliminated.
Skin cannot be sterilized. Air is contaminated by droplets.
HAZARDS IN THE SURGICAL SUITE
•
Electrical
•
Cautery Units, Defibrillators, OR Beds, numerous pieces of equipment
All equipment must be checked for electrical safety before use!!
•
Anesthetic Waste
•
Radiation
•
Leaded aprons & shields available for use during procedures.
Laser Safety
•
Protective eyewear for pt & OR team.
•
Doors remain closed with sign - "Danger, Laser in Use."
•
Sterile water available in the room & on sterile field.
•
Smoke evacuation system is to be employed when applicable.
•
Surgery high filtration masks should be worn during procedures that
produce a plume.
General Safety
•
Apply good body mechanics at all times when transferring pts.
•
OR beds & gurneys will be locked before pt transfer.
Operating safety belts will be used for all pts.
•
Never disconnect or connect electrical equipment with wet or moist
hands.
•
Discard all needles, razors, scalpel blades & broken glass into special
identified containers.
UNIVERSAL PRECAUTIONS SUMMARY
•
Although the risk of contracting HIV in the healthcare setting is extremely low,
there are other bloodborne pathogens which pose a much more significant risk.
•
Precautions should be followed to reduce the risk of exposure to bloodborne
pathogens.
•
Each healthcare worker should assess their possible risks & take precautions to
reduce these risks.
•
Universal Precautions are designed to protect healthcare workers from
occupational exposure & should be followed when potential for exposure might
occur.
Universal blood & or body fluid precautions should be
consistently used for ALL pts.
Fundamental to the concept of Universal Precautions
is treating all blood & or body fluids as if they were
infected with bloodborne pathogens & taking
appropriate protective measures, including the
following:
•
1) Gloves should be worn for touching blood
& or body fluids, mucous membranes, nonintact skin, or items/surfaces soiled with blood
& or body fluids.
•
Gloves should be changed after contact with
each pt & h&s washed after glove removal.
•
Though gloves reduce the incidence of
contamination, they cannot prevent
penetrating injuries from needles & other
sharp instruments.
•
2) Gowns or aprons should be worn during
procedures that are likely to generate
splashes of blood & or body fluids onto
clothing or exposed skin.
•
3) Masks & protective eyewear should be
worn during procedures that are likely to
generate droplets of blood & or body fluids
into the mucous membranes of the mouth,
nose, or eyes.
•
4) Needles & sharps should be placed
directly into a puncture-resistant leakproof
container which should be as close as
possible to the point of use. Needles should
not be recapped, bent, broken, or
manipulated by hand.
•
5) Hands & skin surfaces should be washed
after contact with blood &/or body fluids, after
removing gloves, & between pt contact.
•
6) Gloves should be worn to cleanup blood
spills. Blood spills should be wiped up & then an
EPA registered tuberculocidal disinfectant
applied to the area. The disinfectant should have
a one minute contact time & the area rinsed with
tap water. If glass is involved, wear double
gloves or heavy gloves. Pick up the glass with
broom & dust pan, tongs, or a mechanical
device.
•
7) Healthcare workers with exudative lesions or
weeping dermatitis should not perform direct
patient care until the condition resolves.

8) Disposable resuscitation devices should be
used in an emergency.

9) Occupational Exposures: Definition

- Puncture wounds
- Needlesticks/Cuts
- Splashes into the eyes, mouth, or nose
- Contamination of an open wound

10) Occupational Exposures:

- Wash the area immediately with soap & water
- If splashed in the eyes mouth or nose have
them properly flooded or irrigated with water
- Notify supervisor as soon as possible
- Call infection control unit for information
regarding blood &/or body fluid exposure
management

General safety – cuts & sticks, lifting, falls,
radiation, burns, hand/foot injuries

Biohazards

Fire Hazards

Laser Hazards
 Compressed
 Trace
Gases
Gases
 Electrical
Hazards
 Substances
 Operational
hazards
Safety Issues in OR
Safety Issues in OR
Safety issues in OR
Safety Issues in OR
Fire Safety-Electrical Issues


Electrical hazards are the cause of numerous
workplace fires each year. Faulty electrical
equipment or misuse of equipment produces heat &
sparks that serve as ignition sources in the presence
of flammable & combustible materials.
Egs of common ignition hazards:
 overloading circuits
 use of unapproved electrical devices
 damaged or worn wiring
Anaesthetic
Machine /
Gas
Fire in the OR
Electrosurgical unit application
Barker, S. J. et al. Anesth Analg 2001;93:960-965
Fire in the OR
LASERS
Retained instruments & sponges
U/sound features of missed pack & The pack is
soaked with altered blood & purulent exudate (arrow)
Gossypiboma: Retained gauze
Retained surgical sponge: an unusual
cause of malabsorption.
Retained instruments & sponges
X-ray of a surgical scissor blade that
broke off that the surgical team didn’t
notice.
X-ray of a retained
clamp that the surgical
team forgot to remove.
Retained instruments & sponges
Surgical sponge that was left in a
patient, identified by the radioopaque thread inside the sponge.
Retained laparotomy pad, Mount Sinai
Medical Center, New York, 1998. ‡
Positioning / Injury / Fall in OR
Positioning / Injury / Fall in OR
Sharps / Needle Stick Injuries in
OR
AANA Position Statement 2.13
Safe Practices for Needle and Syringe Use
www.aana.com
Sharps Safety In the Operating Room

Creating an Injury Prevention Program
Implementation Suggestions

Use scalpel blades with safety blades
Reusable
Disposable
Implementation Suggestions
Alternative cutting methods
 Cautery
 Harmonic scalpel

Cautery
Harmonic Scalpel
Implementation Suggestions

Use blunt suture needles, stapling devices or
steristrips
Blunt suture needle
Steristrips
Stapler
Implementation Suggestions

Keep used needles on the sterile field in a
disposable puncture resistant needle container
Implementation Suggestions

Adopt a hands-free technique of passing suture
needles & sharps between perioperative team
members
Implementation Suggestions

Use a one handed or instrument assisted
suturing technique to avoid finger contact
with needles

Use “control-release” or “pop-off” needles
Implementation Suggestions

Double glove during all surgical procedures
Implementation Suggestions
DO NOT bend, break or recap contaminated needles
If re-capping is absolutely required,
use one-handed scoop technique: (1)
Place needle cap on table
(2) Holding the syringe only,
guide needle into cap
(3) Lift up syringe so cap is
sitting on needle hub
(4) Secure needle cap into place
Sharps Disposal

Closable orange or red, leak-proof puncture
resistant containers

Located close to the point of use maintained
upright

Replaced routinely and not allowed to overfill

Wall / Floor mounted
Sharps Disposal: New Containers
Safety sharps containers
Goal: to Prevent Needlesticks
• Counter-balanced drop in
prevents children’s fingers from
getting in
• Automatically closes at ¾ full –
prevents overfilling
Reusable sharps containers
Goal: to reduce landfill waste
• Outside contractor removes
contaminated sharps, cleans container
and returns it
Retained FB / Surgical Instrument
Retained surgical instruments
Foot-long surgical
tool left in woman's
abdomen
Diathermy – Burns /
Electrocution
Iatrogenic skin burns due to spirit during
laparotomy
IV Lines / Blood Transfusion
Employer Responsibilities

Comply with regulations

Create a safety-oriented culture

Encourage reporting

Analyze data

Provide training

Evaluate devices

Establish safe staffing patterns
Worker Responsibilities

Observe regulations

Comply with methods available

Use & Practice using safety devices

Actively participate in evaluation & safety
conversion process
Worker Responsibilities

Use appropriate PPE

Use appropriate sharps containers

Participate in education and follow
recommendations

Support others to follow the recommendations

Follow hospital exposure control policy
Worker Responsibilities
 Report
Exposures
 Employers required by OSHA to document all staff
exposures to blood / body fluids anonymously
○ Sharps Injury incidence report
 Location, job title, description of incident, type &
brand of sharps involved
 Source testing, risk analysis & post-exposure
prophylaxis if indicated
BARRIERS TO IMPLEMENTATION

Psychosocial & organizational factors

Attitude/Resistance to Change

Shortcomings associated with safety devices

Perceived cost associated with engineered
devices

Inadequate training

Time limitations
Overcoming Obstacles to Compliance

Frequent & multiple training methods

Multidisciplinary sharps injury prevention plan

Educate new employees & all HCWs

Multidisciplinary sharps safety committee

Network with other facilities

Involve front-line workers in evaluation & selection of
safety devices
Other Issues?
Drugs Preparation & Administration.
Substance Abuse (Drugs).