Introduction to SafetyNet: lessons learned from close calls in the OR

AORN Journal,  July, 2006  by Donna S. Watson

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PERIOPERATIVE PATIENTS place their lives in the hands of health care providers at the time they are the most vulnerable. Yet, the Institute of Medicine (IOM) report titled To Err is Human estimates that these very health care providers make mistakes that result in as many as 100,000 preventable deaths annually. (1) This startling report continues to shape how nursing, medical, and public communities view patient safety. The result is a paradigm shift that has progressed beyond placing blame on individuals to analyzing the broader concept of systems that influence patient safety. Perioperative teams across the country are redesigning systems in a proactive approach to encourage open communication. Communication is encouraged to discuss patient safety issues before an actual occurrence results in patient injury. The IOM report continues to shape the focus of health care toward the end goal of safer patient care.

As an organization, AORN has always participated in promoting and influencing patient safety in the perioperative arena. In April 2002, AORN launched the Patient Safety First initiative, an aggressive program to address and respond to issues of concern related to perioperative patient safety. The work of the Patient Safety First initiative continues to address patient safety concerns and issues and influences safe patient care through recommended standards, practices, guidelines, and education. AORN continues to receive national acclaim for its continuous efforts in shaping and influencing safe perioperative practices.

As part of the Patient Safety First initiative, in 2004 AORN launched a voluntary perioperative close-call reporting system, SafetyNet. SafetyNet was inspired by the Aviation Safety Reporting System (ASRS). The ASRS collects, analyzes, and responds to voluntarily submitted aviation safety incident reports in order to lessen the likelihood of aviation accidents. Like the ASRS, SafetyNet allows perioperative clinicians to submit anonymous reports about close calls in the OR. The reporting individual details the clinical situation (ie, narrative story) related to the circumstances of a near miss, close call, or area of concern specific to the perioperative setting.

According to James Bagian, MD, Chief Patient Safety Officer for the Veterans Health Administration and a former astronaut, close calls happen anywhere from 10 to 200 times more frequently than the event of which they are the precursor. For every incorrect surgery that is performed, there are anywhere from 10 to 200 that almost happened, and we can learn from those. (2)

The SafetyNet data are periodically analyzed for patient safety trends. The premise of trend analysis is that once a trend is identified, the reported clinical scenarios can be analyzed to determine various aspects of care, including "what happened, how did it happen, why did it happen, and what can be implemented to prevent future occurrences." It is then determined whether there are actions that AORN can take to reduce the likelihood of a recurrence that could result in patient harm. This might include a patient safety alert, development of recommended practices, position statements, guidelines, tool kits or education programs to influence perioperative practice, or activities such as National Time Out Day to draw attention to actions that perioperative nurses are taking to improve safety.

This first supplement to the AORN Journal supplement showcases SafetyNet. It includes analysis of close calls in the OR represented in stories submitted to SafetyNet. Clinical storytelling is widely used as a teaching concept in formal education for nursing students, during orientation of new staff, and in the active clinical setting. (3) The process of storytelling can take many forms, to include sharing a clinical situation in the classroom or a clinical report with colleagues, to a more formal process of incident reporting. Each SafetyNet story describes a process of events that did not proceed as planned and that resulted in the occurrence of a close call in which a patient narrowly avoided harm.

J T Reason once stated, "The most detrimental error is failing to learn from an error." (4) In reviewing each of the SafetyNet stories, ask yourself the simple question, "Could this occur at my facility ?" If you are like most perioperative nurses, the answer is yes. The SafetyNet stories offer an opportunity to gain insight from the lessons learned and implement appropriate steps toward prevention of error and promoting patient safety. Take the opportunity to enhance your clinical practice by learning from the experiences of others when things went amiss.

As we attempt to increase our understanding of why errors occur, stories will continue to be an important tool in learning lessons from one another's experiences. Every perioperative nurse has a story to tell of a close call or perhaps an actual event. I recall a personal experience that influenced my clinical practice: