SDS Accreditation Update

Expand your mandated pre-procedure timeout to enhance patient safety efforts in the OR

Pre-surgical briefings should include allergies, medications, and more

A decrease in the perceived risk of wrong-site surgery and an improvement in collaboration among members of the operating room team improved significantly following the introduction of a standardized operating room briefing for all surgical procedures performed at Johns Hopkins Medical Institutions in Baltimore.

The study shows that following the implementation of briefings, 91.5% of the staff agreed that "surgery and anesthesia worked together as a well-coordinated team," an improvement over the 67.9% of staff members that agreed with this statement prior to briefings. More than 64% of staff agreed that "a preoperative discussion increased my awareness of the surgical site and side being operated on" following the briefings, compared to 52.4% that agreed prior to the regular use of briefings.1

The Joint Commission identifies communication breakdowns as the most common root cause of wrong-site surgeries, says Martin Makary, MD, MPH, director of the Johns Hopkins Center for Surgical Outcomes and lead author of the study. "Our research indicates that operating room personnel see pre-surgical briefings as a useful tool to help prevent such errors," he says.

Wrong-site surgery represents the second-highest percentage (13%) of sentinel events reported to The Joint Commission, and the most frequently identified root cause for wrong-site surgery is communications. While communication was identified as the root cause in 70% of wrong-site surgeries reported in 2005, this is a drop from almost 80% for wrong-site surgeries reported between 1995 and 2004.

One reason for that decrease is the increasing use of pre-surgical briefings, suggests Fabrizio Michelassi, MD, chairman of the Department of Surgery at New York-Presbyterian-Weill Cornell Medical Center. "We've been doing a pre-surgical briefing for a couple of years now, and we cover more than just the surgical site and side," he says.

Confirming the patient's identity, procedure, and site begins before the patient enters the operating room, points out Michelassi. "In the preoperative area, the site is marked and confirmed by the patient, then as the patient enters the operating room, the nurses verify name, procedure, and site, with the patient before anesthesia is administered," he explains. "Our third and final check is performed once the patient is asleep and just before the procedure begins." Although timeouts are required by accreditation organizations prior to any surgical procedure, Michelassi's surgery program covers more than the basic required information, he says.

All members of the operating team must be present and listening during the pre-surgical briefing, says Michelassi. In addition to patient name, procedure, and site, the team also hears reports on antibiotics or heparin that have been administered, allergies, and special equipment that is needed, to confirm that the equipment is in the room, he says.

Standardize briefings

It is important that all staff members follow the same process for all surgical procedures, Makary says. The standardized OR briefing program has been Hopkins' policy since June 2006, he says. The two-minute briefing at Hopkins addresses the information the Michelassi's meetings cover, but they begin with each member of the OR team stating their name and role. When staff members leave and are replaced by another staff member during the procedure, the new staff member introduces him or herself and restates his or her role, he adds.

"Before the new policy was implemented, many surgeons would walk into the OR and start working without a conversation of any kind and without even knowing the names of the nurses and other staff who were assisting them," he says.

Documentation of the timeout or pre-surgical briefing can be accomplished by notations on a checklist in the chart or, as in the case of Strong Memorial Hospital in Rochester, NY, on a specially designed white board. The board, from Davis International, Fairport, NY, not only helps staff members cover all items, but it stays visible to all team members throughout the procedure.

Ivelisse Vicente, RN, BSN, perioperative nursing safety officer for Strong Health says, "Our surgical pause takes place after the patient is prepped and draped and just before the incision is made. Our pause board contains sections to identify name, procedure, site, antibiotics, beta-blockers, available implants, additional equipment, patient position, blood availability, allergies, and other issues related to safety," she says. Red tags indicate the items that have not yet been discussed, and then green tags are flipped over by the circulator once the item is covered in the surgical pause, she says.

While staff members now like having the information visible throughout the procedure, staff members were resistant at first and viewed the board and the pre-surgical pause as something else to do and fill out, admits Dan Nowak, RN, MS, associate director of perioperative services at Strong Memorial. Once staff members realized that the board is filled out prior to the pause and that the pause takes less than two minutes, everyone saw the value of the process, he adds.

The surveyor for Strong Memorial's most recent accreditation survey was so impressed with the surgical pause board that he is submitting it as a best practice to share with other health care organizations, says Nowak.

While the pause board is well received and appreciated by surveyors and staff members, it is still a work in progress, admits Vicente. "We are redesigning it to include an area that enables us to list the times that we administer prophylactic antibiotics or other medications," she says. They want to keep the process simple and easy to implement, but also be willing to update the process, Vincente adds.

The pre-surgical briefing is a simple concept, Michelassi says. The timeout is mandated by accreditation organizations, but it is very easy to take the basics of the mandated timeout and expand upon it to make it better and make surgery safer, he says. "It is effective because it is often the only time that all members of the operating team have a chance to be together and talk about the patient as a group," Michelassi says.

Reference

  1. Makary MA, Mukherjee, BA, Sexton JB. Operating room briefings and wrong-site surgery. J Amer College Surg 2007; 204:236-243.

Resources

For information on the Perioperative Checklist SliderBoard, contact:

  • Davis International, 388 Maison Road, Suite 1A, Fairport, NY 14410. Telephone: (585) 421-8175, ext. 103. Fax: (585) 421-8707. E-mail: jimd@davisint.com. All orders can be customized to fit each outpatient surgery program's needs, but costs are generally $300 per 2-foot by 3-foot board and $250 for 12-inch by 18-inch board.

For other information, tips and tools for prevention of wrong-site surgery, go to:

  • The Institute for Clinical Systems Improvement, a Minnesota quality improvement organization, offers a free protocol for site verification. The recently revised protocol has algorithms for preoperative, intraoperative, and bedside site verification. To download the protocol, go to www.icsi.org and select "Guidelines and More" from top navigational bar. Select "Other Health Care Conditions" and scroll down to "Safe Site Protocol for All Invasive High-Risk or Surgical Procedures (Protocol)." Choose the "+Show Additional Materials" link to display options for the summary as well as documents.
  • Institute for Healthcare Improvement offers a variety of free tools related to surgical safety issues. Go to www.ihi.org. Click on "topics," and select "patient safety." Choose "safety: general" and "tools." Scroll down to find "General Tools." A list of available tools includes "Procedural Pause Audit Tool."