Tips to Improve Patient Safety in the OR

By ALISON McCOOK

Even the most routine procedure can quickly become unconventional. A hysteroscopy can result in a uterine–sigmoid colon perforation; a sponge can be left in a patient after surgery; or a patient can develop an infection from a device that wasn’t properly reprocessed. The list of things that could go wrong— putting the patient’s safety at risk—is endless.

Adverse events cannot be prevented completely, but lessons can be drawn from them. That was the goal of a recent study by the nonprofit ECRI, which reviewed nearly 2,000 adverse surgical events that were voluntarily reported by OR staff at hospitals around the United States between 2018 and 2019. During the Association of periOperative Registered Nurses (AORN) 2021 virtual Global Surgical Conference & Expo (session 8837), Gail Horvath, MSN, RN, the senior patient safety analyst and consultant at ECRI, grouped the results into types of surgical mistakes, and presented tips to avoid them.

Complications

Approximately half of the adverse events reviewed by ECRI were classified as complications, often related to either anesthesia or the surgery itself, such as bleeding or perforation. Complications are unavoidable, but there are ways to reduce the chances they will happen, Ms. Horvath said. For instance, facilities should follow evidence-based recommendations, such as tips to avoid pressure injuries, from the Joint Commission. They can conduct root cause analyses of past adverse events, she said, and analyze current processes to determine ways they can fail. In addition, staff should undergo skill retraining and refresher courses on a regular basis, which “are vital to reducing the risk of surgical complications.”

Room and Patient Readiness

In three out of 10 incidents reviewed, either the patient or the room wasn’t ready at the time of surgery. It’s more than just an inconvenience, Ms. Horvath said. “Ensuring rooms are properly set up is really essential to getting your patient safely through the procedure.” A robust preadmission process will help develop a good perioperative plan of care, and identify information gaps and other issues that could lead to delays. Make sure your informed consent process is airtight, she noted, as it’s “much

more than getting a signature on a piece of paper.” It’s also giving the patient or their representative all the information they need to evaluate the risks and benefits of the procedure. One way to avoid readiness issues is to conduct a preoperative briefing before bringing the patient into the OR, suggested Lisa Spruce, DNP, RN, the director of evidence-based perioperative practice at AORN. During the briefing, staff can review the lete- planned procedure, pertinent lab results or radiographs, patient hat position planned, pressure injury risk, equipment or instruments f- needed, the plan for patient skin antisepsis, “and any other quesse tions or safety concerns,” she said. ed

Retained Surgical Items

Roughly one-fourth of the reported adverse events involved a surgical item mistakenly left inside the patient, such as needles, Gail Horvath, MSN sponges or device fragments like catheter tips. These small items “can go unnoticed, but can result in devastating consequences for the patients,” Ms. Horvath said. Staff within each facility may follow different count practices (AORN J 2012;95[2]:228-238), which can put patients at risk. A key step, said Ms. Horvath, is to standardize count policies and procedures, including the timing of counts, and which items should be counted. Facilities could consider adopting a “sterile cockpit” approach to counting, based on an aviation policy that prevents nonessential activities during critical flight periods. “The sterile cockpit approach during surgery will help patients by reducing distractions during key moments in the operation,” she said.

Contamination

Infection control is a major issue at every hospital. To minimize the impact of contamination on your facility, Ms. Horvath recommended continuously reviewing and updating reprocessing protocols and workflows, to make sure they are both effective and realistic. Reprocessing staff must be properly trained (and retrained) and shouldn’t get overloaded, which can force them to skip steps. Good communication between the OR and sterile reprocessing is crucial, she added, so that neither blames the other for any failures. “It’s critical that you foster collaboration and teamwork between these two essential departments.”

Equipment Failures

Although equipment failures made up only 5% of the reported incidents analyzed, they can have major consequences for