Creating a patient-safe environment in a perioperative setting

AORN Journal,  Jan, 2005  by Lynne Karanfil,  Jan Bahner,  Rosalie Most

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Although patient safety always has been a focus in the OR, emphasis on this topic has been renewed as a result of new regulatory requirements and high consumer demand for optimal health care. MedStar Health, Inc, Columbia, Md, is a not-for-profit, community-based health care organization composed of 25 integrated businesses, including seven major hospitals and two freestanding ambulatory surgery centers. MedStar Health, a community-owned, academically oriented health care delivery system, provides comprehensive health care services. Its patient-first philosophy combines care, compassion, and clinical excellence with an emphasis on customer service. In 2001, a corporate patient safety project was initiated within the MedStar Health organization. This article presents the perioperative safety assessment process that was designed, pilot tested, and implemented in the organization's six ORs and two ambulatory surgery centers.

Background

In 1998, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) began publishing sentinel event alerts. Four of these alerts (ie, 6, 12, 24, 29) have focused on OR issues. (1-4) In December 2002, JCAHO announced its patient safety goal initiative. At that time, there were six patient safety goals for 2003. The goals that related to the OR were

* improving patient identification; and

* eliminating wrong site, wrong patient, and wrong procedure surgery.

In 2003, JCAHO published its Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. For the same year, JCAHO sentinel events trends indicated that approximately 15% of total sentinel events occurred perioperatively, representing approximately 70 wrong-site surgery events. (5) In the root cause analysis of these surgical sentinel events, communication and orientation or training were cited as the top two causes of the events.

Materials and Methods

As part of its patient-first philosophy and commitment to patient safety, MedStar Health began planning for a perioperative patient safety project in November 2001. Consultants in resource management, an internal consulting department within MedStar, were tasked with directing this perioperative safety project based on a medication safety project they had developed and implemented successfully. Some of the components necessary for improving patient safety include

* assessing compliance with policies and procedures,

* collecting and analyzing data,

* conducting performance improvement initiatives,

* educating and training employees,

* fostering teamwork and communication, and

* reporting incidents and close calls.

Initially, resource management department consultants developed a work plan to outline the project's course. Their first major step was to perform a literature search using the Internet and resources from AORN. They also gathered guidelines from JCAHO, the American Society of Anesthesiologists, the American College of Surgeons, and the American Academy of Orthopedic Surgeons. From these resources, the consultants developed a staff member questionnaire to gather information on staff member knowledge of patient safety issues (Table 1). The consultants also developed a risk assessment tool for the following eight focus areas:

* general safety;

* anesthesia safety;

* burns;

* correct patient, site, procedure, and equipment;

* laser safety;

* latex safety;

* retention of foreign objects; and

* vendors in the OR (Table 2).

Assessment Process

One of the MedStar hospitals volunteered to participate as the pilot facility for testing the assessment tool and process. The eight sections of the tool were used to assess whether perioperative policies incorporated recognized standards and guidelines and whether staff members were compliant with the standards. In addition, basic aspects of infection control also were reviewed; for example, the placement of internal sterilization indicators in sterile pack ages was checked.

After the pilot test was completed, the consultants performed the assessment at the other facilities. This included preassessment, assessment, and postassessment phases.

Preassessment phase. During the preassessment phase, resource management consultants obtained policies, procedures, and other documents related to the OR from the site. The consultants reviewed all information regardless of whether it was linked directly to patient safety.

Assessment phase. The assessment phase at the pilot site included three days of OR observations performed by two resource management consultants. The amount of time spent at the other sites depended on each facility's size. During the first day of the assessment, resource management consultants presented an overview of the perioperative safety project to introduce it to key leaders and to allay staff member concern. An anonymous questionnaire was distributed to staff members to glean their input regarding perioperative patient safety issues. After collecting the questionnaires, resource management consultants took a brief tour of the OR with OR leaders to observe environmental safety and infection control issues.