Patient Safety First: looking back, looking forward

AORN Journal,  July, 2006  by Donna S. Watson

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In April 2002, AORN launched its Patient Safety First initiative. The initiative was developed in response to a widely publicized report from the Institute of Medicine estimating that between 44,000 and 98,000 deaths occur annually as a direct result of medical errors. (1) To put these numbers in perspective, if medical errors were reported in the Centers for Disease Control and Prevention's annual National Vital Statistics Report, they would rank as the sixth leading cause of death in the United States. (2) These preventable errors result in more annual deaths than diabetes, influenza and pneumonia, Alzheimer's disease, breast cancer, and renal disease. (2) Additionally, there are economic consequences from medical errors that do not result in death but may result in extended hospitalization, prolonged recovery, and patient disability. The Patient Safety First initiative focuses on decreasing errors in surgical settings and creating resources to help perioperative clinicians provide safe patient care.

The first exclusive sponsor of Patient Safety First was Sandel Medical Industries, Inc, which donated $1 million toward Association efforts to promote patient safety. Dan Sandel, president of Sandel Medical Industries, is well-known to the members of AORN and has been a patient safety advocate nationally. He is passionate about promoting patient safety and respects nurses' contributions to safety efforts. He continues to serve as a liaison to the Presidential Commission on Patient Safety.

The Presidential Commission on Patient Safety is the governing body of Patient Safety First. At the commission's initial meeting in 2002, members identified the following priorities for the initiative:

* correct site and patient identification;

* communication in the OR and among health care providers;

* counts (ie, unplanned foreign object retention);

* human factors;

* inadvertent hypothermia;

* infection control;

* medication safety;

* positioning injuries; and

* promoting a safety culture in health care facilities.

Many of the Association's activities in the past four years have focused on these priorities. Projects have included the development of guidelines, recommended practices, position statements, tool kits, and a variety of education programs in different formats to address patient safety issues at local and national levels. The projects are collaborative efforts among various AORN committees that include a diverse representation of members. Some also involve other members of the perioperative team or outside experts on a particular subject. This article highlights some of the Association's safety efforts.

CORRECT SITE SURGERY

AORN has been active in developing resources that promote a consistent approach to preventing wrong site surgery, including participation in the collaborative development of the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO's) Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. (3) The Universal Protocol includes a preoperative verification process; a process to mark the intended site of the procedure; and a "time out" immediately before the procedure commences to verify the correct patient; procedure; and site, including laterality. AORN's "Position statement on correct site surgery," (4) which incorporates the Universal Protocol, was ratified by the AORN House of Delegates in New Orleans in April 2005.

AORN's Correct Site Surgery Tool Kit was developed to provide perioperative nurses with additional resources and guidance for successfully implementing the Universal Protocol. The tool kit includes a CD-ROM explaining the Universal Protocol; a pocket reference card outlining the steps for patient identification, surgical site marking, and conducting the time out; and a template that facilities can use to develop their own policies for implementing the Universal Protocol. The tool kit was distributed to all AORN members and to facility administrators, risk managers, surgeons, and anesthesia care providers across the country in April 2004. It is endorsed by the American College of Surgeons, the American Society of Anesthesiologists, the American Society for Healthcare Risk Management, the American Hospital Association, and the American Association of Ambulatory Surgery Centers. Endorsements such as these help facilitate implementation of policy at the local level. The tool kit materials are now available at http://www.aorn .org/toolkit/nmdefault.asp.

The first National "Time Out" Day was held on June 23, 2004, to promote adoption of the Universal Protocol. This event received national media coverage and helped educate the public about patient safety and the importance of perioperative nurses in the OR. On June 22, 2005, National "Time Out" Day focused on medication safety and labeling. The theme for the 2006 National "Time Out" Day, held on June 21, was "Taking a Time Out for Safety ... Every Patient, Every Time." This broader theme emphasizes the need for continual vigilance about patient safety.