SURGICAL SAFETY CHECKLISTS

Transcription

1 1 SURGICAL SAFETY CHECKLISTS Power Play: Managing the Forces that Impact Implementation The Experience of a small isolated community hospital Presentation by: Mark Balcaen. March 8-9, 2010

2 2 Background Kenora (230 km from Winnipeg) 84 beds (Med/Surg/Mat/Peds/Psych/Chr) 2 General Surgeons 3 Visiting Specialist Surgeons 8 Dentists and 3 GP s Doing Minor Surgery 5 GP Anesthetists 8 Surgical Services Nursing Staff (3 OR s) 2400 Surgeries / Procedures per Year (80%+ NFA) Ontario Wait Times Strategy Site

3 3 Previous Practice Nursing OR Checklists. Surgeons Preference Cards. Procedure Consent Form. Patient May Have Been Anesthetized Prior to Entire Surgical Team in the OR. Communication problems between ST members.

4 4 Impetus to Adopt Lack of Mind-Reading OR Nursing Staff Incident Reports related to Intraoperative Issues OR Lab Specimen Errors OR Equipment and Supplies Issues Anesthesia Related Incidents Possible Means to Address Long-Standing OR Communication Issues Desire to be ahead rather than to Catch-up No Significant Additional Resources Needed

5 5 Roll Out Approach Slowly Gain Support as You Go Identify Key Champions Excellent CPSI Tool Kit Persistence

6 6 Implementation Feb 19/09 SSL Presentation to Hospital SSC and Senior Management Apr 10/09 Trial Checklist in OR Evaluate Checklist Trial Revise Checklist as Necessary Retest Checklist Start Monitoring and Recording Results Apr 23/09 Report Successes, Good Catches, Near Misses. Make Checklist Modifications Continue Monitoring Results Apr 30 / 09 Brief SS Group on Findings Celebrate Successes

7 7 BRIEFING Before induction of anesthesia All team members in the theatre and names written on white board beside corresponding roles (observers included) Patient information confirmed Identity (2 identifiers) Consent: Site and procedure (by nurse) Site, side and level marked Clinical documentation: History, physical, labs, of significance ANESTHESIOLOGIST: (WITH ALL TEAM) Anesthesia equipment safety check completed ASA score Check sheet placed on patient chart Special precautions? Allergies? Medications Beta blockers? Glycemic control meds? PreOp Anticoagulant therapy (e.g., Warfarin)? Preop Antibiotic administered Difficult Airway / Aspiration Risk Confirm equipment available if required: Specific patient concerns, critical resuscitation plan Monitoring vs, O2 sat, Temp Probe, Foley, Bair hugger (if applicable) If blood loss issues (G & M done & in chart) SURGEON : (WITH ALL TEAM) Specific patient concerns, critical steps, and Special instruments or implants Final optimal positioning of patient NURSES: (WITH ALL TEAM) General Surgery SURGICAL SAFETY CHECKLIST Lake of the Woods District Hospital Your Organizational Logo PAUSE / TIME OUT After draping / immediately before incision Surgeon, Anesthesiologist, and Nurse verbally confirm Patient Procedure Site Side Level Is prep solution dry? Is all equipment connected and ready to proceed? Does anyone have any other questions or concerns before proceeding? DEBRIEFING As soon after skin closure as possible / before patient leaves OR All team members review with entire team Surgeon states procedure performed Important intra-operative events Anesthesiologist reviews intraop events Recovery plans where there are KEY concerns for this patient s recovery and management Changes to post-operative destination? Nurse reviews: Surgical count correct Specimen labeling accuracy Any equipment malfunctions? Action taken? Your Organizational Logo Sterility indicator Specific patient concerns? Equipment / implant readiness Could anything have been done to make this case safer or more efficient?

8 Pre-Anaesthesia Apparatus Checkout 8 A. Pipelines Secure connections between terminal units (outlets) and anaesthetic machine B Check here if this is a repeat case today with this machine: CHECKED items to C. Breathing Circuit 1 Turn on machine master switch and all necessary electrical equipment line oxygen (40 60 psi or KPa) line nitrous oxide (40 60 psi or KPa) adequate reserve cylinder oxygen pressure adequate reserve nitrous oxide content check for leaks and turn off cylinders flow meter function of oxygen and nitrous oxide over the working range. 2. vaporizers filled / filling port closed / on-off functions work 3. Functioning oxygen bypass (flush) 4. Functioning oxygen fail-safe device 5. Attempt to create a hypoxic 02/N20 mixture and verify correct changes in flow and/or alarm 6. functioning common fresh gas outlet 7. ventilator function verified 8. backup ventilation equipment available and function cylinder, Ambubag 1. circuit correctly assembled & presser checked 2. connected to common gas outlet 3. Oxygen flow meter turned on 4. Check for exit of fresh gas at face mask 5. Functioning high pressure relief valve 6. Unidirectional valves and soda lime 7. Functioning adjustable pressure relief valve D. Vacuum Suction adequate E. Scavenging Correctly connected to patient circuit and functioning F. Routine equipment 1. Airway Management Functioning laryngoscope (back up available) Appropriate tracheal tubes: patency of lumen and integrity of cuff Appropriate oropharyngeal airways Stylet Magill forceps 2. IV supplies 3. BP cuff of appropriate size 4. Stethoscope 5. ECG monitor 6. Pulse oximeter 7. Capnograph 8. Temperature monitor 9. Functioning low and high pressure alarms G. Drugs Adequate supply of frequently used drugs and intravenous solutions H. special equipment Resuscitation apparatus is present and working Defibrillators / crash cart Emergency drugs Difficult intubation kit Glidescope bronchosope Anaesthetic Machine Room Number: O.R. # 1 O.R. # 2 O.R. # 3 DATE of inspection TIME of inspection Anaesthetist Signature: Canadian Anesthesiologists Society, Place patient identifier sticker here

9 9 BRIEFING Before induction of anesthesia Hand-off from day surgery nurse All team members names written on white board beside corresponding roles Anesthesia equipment safety check completed Check sheet placed on patient chart Suction available Patient information confirmed Identity (2 identifiers) Consent: Site and procedure (by nurse) BIOMETRY (confirm patient ID on sheet) (by ophthalmologist) Clinical documentation: (by anesthetist) History, physical, labs, of significance Special precautions? Allergies? Medications EYEDROPS # of sets administered Beta blockers? PreOp Anticoagulant therapy (e.g., Warfarin)? Difficult Airway / Aspiration Risk Confirm equipment and assistance available Ophthalmologist review: Specific patient concerns, critical steps, and special instruments or implants Final optimal positioning of patient Anesthesiologist(s) review(s) Specific patient concerns, critical resuscitation plans, and warming devices required ASA Class Nurses(s) review(s) Specific patient concerns? Sterility indicator passed? Equipment issues? Correct implant (and back up) available? Monitoring Pulse oximetry, ECG, BP Cataract /IOL Surgery SURGICAL SAFETY CHECKLIST Your Lake of the Woods Organizational District Hospital Logo PAUSE / TIME OUT Before incision Surgeon, Anesthesiologist, and Nurse verbally confirm Patient Site, side Procedure Does anyone have any other questions or concerns before proceeding? DEBRIEFING Before patient leaves OR Nurse reviews with entire team Important intra-operative events Specimen labeling and management (if required) Equipment Malfunction? Action taken? Changes to post-operative destination? What are the KEY concerns for this patient s recovery and management? Could anything have been done to make this case safer or more efficient? Hand-off to RR Your Organizational Logo

10 10 ENDOSCOPY SURGICAL SAFETY CHECKLIST Lake of the Woods District Hospital BRIEFING - ENDOSCOPY This discussion is held once all surgical staff has arrived in the operating room and prior to the administration of the neurolept Patient is usually awake and aware at this time. Anaesthesia equipment safety check completed? ASA class stated Monitoring pulse oximetry on, ECG, BP, Anaesthesiologist: - Any specific patient concerns Patient Information confirmed. - 2 identifiers, consent states: procedure - Documentation H&P? Allergies? Surgeon - any specific patient concerns is cautery is required? Prepared for biopsy to be done? Disposable biopsy forceps/snares etc available? Nurse - any specific patient concerns Equipment checked / operating well Suction / irrigator working? Medications Glycaemia control? Off antiplatelets for appropriate length of time? (Plavix? ASA? NSAIDS?) Special precautions? TIME OUT Discussion occurs IMMEDIATELY before scope insertion Surgeon, Anaesthesiologist and Nurses verbally confirm patient, procedure, DOES ANYONE HAVE ANY OTHER QUESTIONS OR CONCERNS BEFORE PROCEEDING? Surgeon reviews: - procedure, - post op diagnosis - CIRT RECORDING Anaesthesiologist: KEY concerns for this patient s recovery and post operative management DEBRIEFING This discussion occurs at LIGHTS ON phase Each professional reviews with the entire team Nurse reviews: specimen identification: i e: correct labelling and management important intraoperative events including if equipment malfunctions occurred COULD ANYTHING HAVE BEEN DONE TO MAKE THIS CASE SAFER OR MORE EFFICIENT?

11 11 Accomplishments First Small Hospital in Canada to adopt and fully implement the Safe Surgery Saves Lives Program February 19 April 30, 2009 Significant Good Catches to date

12 12 Challenges Those Who Said This is for Big Hospitals it does not Apply to us Nurses Needed to Become Comfortable Asking for the Information Overcoming the Nay Sayers Adapt the Program to the Type of OR (small cases cataracts, colonoscopies)

13 13 Successful Tactics Dependent on Organization Culture Dependent on Individuals Involved Type And Size of Organization Champions What Are Peers doing? Personal Persuasion Skills (soft management / leadership skills) Mandatory Patient Safety Reporting Measure

14 14 Benefits of Involvement This is About Improved Communication Very Economical to Implement Empowers Nurses to Speak out for Patient Safety Pride in Providing Safest Surgery Possible Research Proven to Save Lives and Prevent Complications Participation in an International Program that Identifies our Hospital as a Leader in Patient Safety

15 15 LWDH Champions Sonia June Hill RN,MN, Manager Surgical Services Dr. Jack Spielman, Chief of Surgery Dr. Murray Workman, Chief of Anesthesia Brigitte Loeppky, OR Team Leader