Transcript Patient Safety - Yale-New Haven Hospital | School of Nurse

Patient Safety
Marianne Cosgrove, CRNA, DNAP, APRN
Human Error

An inappropriate or undesirable
human decision or behavior that
reduces or has the potential for
reducing:
effectiveness
 system performance
 safety

Healthcare Errors

Non-intended healthcare outcomes
resulting from a defect in the delivery of
care to a patient
Errors of commission
 Errors of omission
 Errors of execution


These occur on a daily basis in the OR!
To Err is Human
A report published by the Institute of
Medicine (IOM) in 2000
 Found that:

Errors will happen
 Some errors are predictable
 Some errors are preventable
 Causation is typically multifactorial

AHRQ (Agency for Healthcare Research and Quality)
Follow-up study to IOM report over 3
years (2000, ’01, ‘02)
 Noted that the IOM report represented
the “tip of the iceberg”



Underreporting is an issue
195,000 deaths/year due to preventable
error!
Error
May be active (the person makes a
mistake)
 May be latent (the person is dealing
with a system which has a hidden
deficiency)


A.K.A. “resident pathogens”
Reason’s “Swiss Cheese Model”
Critical Incident (CI)
 An
accident
 An event that could have
(if not quickly resolved) or did
lead to a major complication.
CI at HSR - 2004
Error and anesthesia
“Anesthetists work in a risky
environment where one small mistake
can have catastrophic results.”
 Human error can never be eliminated,
however…

it can be predicted
 systems can be designed to minimize
mistakes

Set-ups for error
Use of complex machinery
 Variability in patient

disease
 response to anesthetics,
interventions

High degree of uncertainty
 Interventions are risky
 Unfamiliarity with setup

“Look-alikes”
vasopressin and atropine
metoprolol and rocuronium
The front of the medication drawer @ HSR
Note the color similarity of neostigmine (behind glycopyrrolate) and lidocaine 1%
Set-ups for error

OR environment
High stress
 Multiple personalities
 Cramped working space
 NOISE

Human factors leading to error
Lack of knowledge
 Inadequate communication
amongst team members
 Haste
 Distraction (iPhones, BlackBerries!)
 Fatigue
 Anxiety
 Failure to perform normal checks
(machine, pt chart)

Anesthetists work
in a risky
environment
where one small
mistake can have
catastrophic
results
Anesthesia-related factors
associated with CIs
Inadequate trainee supervision
 Drug misadventure (commonly OD)
 Airway obstruction
 Aspiration
 Insufficient monitoring
 Production pressure
 Insufficient information
 Task density too great
 Poor communication (between pt
and provider or among providers)

Modalities for increasing
safety
SLOW DOWN
 Check, and check again
 “forcing functions”

Tinting gtts with dye
 Physical barriers to use

Infection
HANDWASHING
 Gloving/changing gloves frequently
 Safe injection practices
 Cleaning equipment between patients
 Pronovost’s landmark study (NEJM ‘06)

Pronovost
checklist:
•
•
•
•
•
HANDWASHING
Full barrier
precautions
Chlorohexidine
scrub
Avoidance of
femoral site
D/C of line ASAP!
Development of “checklist” for central
line insertion
 Catheter-related bloodstream infection
rate dropped to nearly zero%

Infection Control
4-5 thousand people /year die from
Hep B/C
 250 HCW die annually from HBV
 The virus is most efficiently
transmitted by blood exposures
 Immune globulin not effective in
prevention
 1992 OSHA required vaccinations
available to HCW free of charge for
HBV.

Infection Control

Outbreak in
Nevada/Arizona
 Endoscopy
Center/Oncology
Clinic-in the news
 Hep B/C
 40,000 patients are
currently being
tested
 Facility
closed/practitioners
lost licenses.
Infection Control

CDC



Policies aimed at protecting the public
Recommendations, not mandatory
OSHA



Standards MUST be followed
Required personal protective clothing and
equipment
Also required:
• Hepatitis B vaccinations, work practice controls,
medical surveillance signs/labels, annual training

Violations carry up to $70,000 fines for
EACH occurrence
Infection Control

Exposure Prone
Procedures


Digital palpation of a
needle in a body cavity
Simultaneous presence of
a needle and finger in area
with poor visibility/confined
area
Highest Risk- NOT US !
BUT…..
Infection Control

What do I do if I get exposed

Post exposure Management
• OSHA standard
• Facility must have program in place to
provide post exposure testing,
counseling, monitoring and surveillance
• Patient exposed due to HCW will receive
the same care
• Medical records
• Kept for 30 years beyond the duration of the
employment
Infection Control

What to do if you
are exposed




Wash with soap
and water
Report
Follow guidelines
Report to
occupational
health clinic
Infection Control

Tier 1= Standard Precautions






Universal precautions
Treat bodily fluids as if all are
infected
Wash hands before and after
all contact**
Wear gloves and other PPE
when necessary
Used needles and syringes in
puncture resistant containers
Do not recap needles
Infection Control

Tier II=transmission
based precautions

Airborne Precautions
• Droplet nuclei 5
micrometers or
smaller
• Wear special mask
• Reverse isolation
room

Droplet precautions
• larger than 5
microns
• Wear a mask within
3 feet of patient
Infection Control

TB






Delay procedure if possible
Inform all staff
Patients should wear masks
outside the isolation area
Anesthesia providers should
wear mask (N-95)
Use bacterial filter between
patient and breathing circuit
Recover in negative pressure
room-PACU
Infection Control

Infected patients in the OR





Decrease traffic
Use disposables
All re-usable equipment must
be sterilized
Personal items should remain
outside the OR
Patients on contact isolation





MRSA
VRE
Impetigo
Herpes
Viral conjunctivitis
Infection Control


“ Outbreaks of viral and
bacterial infections
have been traced to
contaminated multidose vials” ASA
Recent study showed
that 38% of anesthesia
providers admitted to
re-using
syringes/needles on
more than one patient
Infection Control

Administration of drugs
and solutions



Strict aseptic technique
Clean stopper with alcohol
Sterile syringe and access
devise
• If this is not done ,treat the
vial as single use
• Patient safety outweighs
cost savings



No recapping of needles
Needles and syringes are
single use
Needle to test regional
block- single use
Infection Control

Administration of
drugs and solutions
cont.



Do not use bags or
bottles of IV fluid as a
common source of
supply for multiple
patients
Clean amps with
alcohol before
breaking
Stopcocks and
injection ports are
major sites of
contamination
Antibiotic protocol in OR
cefazolin *- Start within 1 hour of incision; bolus over 3-5 mins
 vancomycin *- Start within 2 hours of incision; infuse slowly in 250

ml 0.9 ns or D5W
clindamycin - Start within 1 hour of incision; infuse over 15 mins
 gentamicin - Start within 1 hour of incision; infuse over 30 mins
 levofloxacin - Start within 2 hours of incision; infuse over 30-60

mins

cefotetan - start within 1 hour of incision; bolus over 3-5 mins
* most commonly used ABX in HSR OR
***Document start time as time of administration:
MUST BE PRE-INCISION!!***
Infection Control


A few more notes on infection
 Marker on IV bags
 Tape on IV poles
 Anesthesia machine
 Gloves and your pen
Traffic patterns
 Unrestricted=traffic not limited
 Semi-restricted=traffic limited
• Scrubs and hair covered
 Restricted=hats and masks
• OR suites and sterilization
areas
• Limited traffic
• Enter from scrub room
door
Communication



Some studies indicate 70 to 80 percent
of medical errors are related to
interpersonal interaction issues.
It has been noted that in 63% of sentinel
event occurrences, communication
breakdown is the leading root cause.
Poor communication has also been
identified as the primary factor of both
medical malpractice claims and major
patient safety violations, including errors
resulting in patient death
Communication

Patient
identification

Time out

SBAR

Hand offs
Communication


Originating from the nuclear submarine
service, SBAR stands for:
S - Situation: What is happening at the
present time?
B - Background: What are the
circumstances leading up to this
situation?
A - Assessment: What do I think the
problem is?
R - Recommendation: What should we
do to correct the problem?
Communication
The "time out" occurs when the
patient arrives in the operating room.
 All members of the operating room
team must cease all activity and focus
their attention on the patient.
 The first member of the
team presents their pertinent
information relating to the ensuing
surgical procedure, the patient's name
and medical record number

Communication

Time out: Circulating nurse
Patient’s name and ID#
 States the type of surgery to be
performed
 The site of the surgery which has
already been marked prior to entering
the O.R.
 Antibiotic, if required, is given


The cascade reporting continues until
all involved in the surgery have voiced
their respective obligations or
concerns.
Fire Safety

Heat (Ignition source)





Oxidizers



Lasers
Electrocautery
Drills
Light sources
O2
N 2O
Fuel





ETT
Sponges
Drapes
Hair
Prep solutions
Fire Triad
Fire Safety

O2 rich mixtures



Endotracheal tube



Any concentration
above 21%=OEA
N2O
PVC
Laser tube
Nasal O2
Fire Safety




head/neck surgery under
monitored anesthesia
care has emerged as a
high-risk setting for
operating room fires;
burn injuries represent
20% of monitored
anesthesia care-related
malpractice claims
95% of which involved
head/neck surgery.
Curr Opin Anaesthesiol. 2008
Dec;21(6):790-5.
Fire Safety

Airway fires
Remove the ETT
 Stop the flow of airway gases
 Remove flammable materials from the
airway
 Pour saline into the airway


Non-airway fires
Stop the flow of O2
 Remove burning or flammable
materials
 Extinguish fire

fire safety videos
http://www.apsf.org/resource_center/fire-safety-video.mspx
Falls

FROM:
 Transfer from stretcher to
the OR table
 Table or bed not locked
 Open side of the table
unprotected
 Safety belt not on
 Lack of vigilance
NEVER
TURN
YOUR
BACK ON
A
PATIENT!!




Family sues in
operating room fall
Matriarch suffered a
fatal head injury
January 29, 2008
Moments after
undergoing surgery to
replace a broken hip,
an 86-year-old
Dorchester woman fell
from an operating
room table at Boston
Medical Center,
causing a massive
head injury that killed
her a week later, her
family said in a lawsuit
filed yesterday.
Production Pressure
Rushing leads to error!
Production Pressure
Documented events due to production pressure
include:
 inadequate evaluation
 unidentified contraindications to surgery
 Some causes include:
 A need to work agreeably with surgeons
 To avoid delaying cases
 To avoid litigation
 Due to pressure by surgeons to proceed
with cases instead of cancelling them.
 to hasten anesthetic procedures. (Some
aspects of production pressure were
perceived differently by those reimbursed by
fee-for-service versus those paid by salary).
 Time is money
Production Pressure, cont’d

CONCLUSIONS: Production
pressure from internal and external
sources is a reality for many in
anesthesia and is perceived in
some cases to have resulted in
unsafe actions being performed.
Anesthesiology. 1994 Aug;81(2):488-500.
Production pressure in the work environment. California anesthesiologists' attitudes and experiences. Gaba DM, Howard
SK, Jump B.
Department of Anesthesia, Stanford University School of Medicine, California.
STRESS

Mild stress is necessary for
functionality in anesthesia


Minor to moderate stress is
motivational – assures vigilance
Yerkes-Dodson Law (1908):
Sustained stress leads to…
Fatigue
 Anxiety
 Maladaptive behaviors
 Memory impairment
 Inadequate problem solving
 “tunnel vision”
 Increases in response time
 Low self-esteem, feelings of
inadequacy, depression, anger
 ERRORS

I’ve made an error. Now what?

Reporting is crucial

Practitioners hesitant to come forward
secondary to
• Fear of punishment
• “Hindsight bias” of colleagues
• “Name, blame, shame game” at
M&M rounds
Emotions
Fear
 Guilt
 Humiliation
 Embarrassment

 Errors
should be viewed as
learning opportunities
Building a culture of safety
Work as a team member
 Lead, don’t command
 Accept criticism
 Support/have empathy for colleagues
 Be honest in self-appraisal
 Report events/incidents
 Have a sense of responsibility to
practice safely; ensure that others do
as well

ACRM-Anesthesia Crisis
Resource Management

Cues takes from aviation industry –
allows for:
Practice of situational awareness
 Planning for “worst case scenarios”

• algorithms
• simulation
Be prepared!!
 Be vigilant!!

“Human error…is
inevitable. The goal of
ACRM is to reduce the
likelihood of error,
catch errors that do
occur before they
impact on the patient
or to fix errors before
they progress
further.”12
Fletcher, J. ERR WATCH: Critical thinking and crisis management for the anesthetist. [excerpt]. AANA Journal Course. 1998; 66(6): 7.
For additional info,
articles, videos, etc,
please refer to the
Anesthesia Patient Safety
Foundation’s website:
www.apsf.org