Follow these safety tips to avoid surgical errors
Outpatient surgery providers who want to improve their safety record should follow these six tips, based on a list of suggestions published by authors of a study on safety errors in otorhinolaryngology.1
- Have consults, tests, and personnel in place before surgery. If there are contraindications to elective surgery, consider carefully whether the procedure should be performed.
Contraindications and patient allergies should be discussed with the patient, emphasizes Lori Bartholomew, director of research at Physician Insurers Association of America in Rockville, MD.
In procedures involving cancer, growths, or lymphoma, ensure the tests have adequately identified where the growth has occurred so the surgeons knows the dimensions necessary for excision, says Stephen Trosty, JD, MHA, CPHRM, director of risk management and continuing medical education at American Physicians Assurance Corp.in East Lansing, MI.
"You don’t want to have to go in again or miss something," he stresses.
Appropriate blood tests are necessary to ensure the patient doesn’t have an illness that contraindicates surgery, Trosty says. Also, type and cross-match the blood type and make sure you have the right type available in the event the patient experiences blood loss and needs a transfusion, he advises.
"Make sure all that is done ahead of time and returned to the surgeon and to the specialist ordering the test or the family practice physician," Trosty says.
- Have a tracking system to ensure the correct test is ordered; the correct test is completed; and the results are reviewed.
In outpatient surgery, surgeons often arrive just before a procedure, Bartholomew says. For that reason, you need to ensure your ancillary services are top-notch and you’re receiving reliable information from them in a timely manner, she explains.
It’s particularly important that your ancillary services are dependable because in outpatient surgery, surgeons often practice in multiple facilities and may have to adapt to different protocols at different locations, Bartholomew says.
"Surgeons come in at the nth hour; or they move to the next OR, and there’s not a lot of time to communicate," she points out. "Make sure the anesthesiologist did his work, and make sure all the X-rays are there."
- Check cautery meticulously for intact insulation. Consider using a disposable cautery.
Cautery burns are not as infrequent as outpatient providers would like for them to be, Trosty says. There’s a couple of reasons for the frequency, he says. "One is the malfunction of equipment, or someone monitoring the patient isn’t paying enough attention and the equipment is left too long on a patient or a particular area," Trosty says.
- When sophisticated equipment fails, you may find it difficult to fix it immediately. Have appropriate support for equipment and if it’s possible, test equipment before induction.
In outpatient surgery, complex equipment including drills, image-guided systems, or microscopes may fail. And complex equipment frequently isn’t replaced easily in an outpatient surgery setting, Bartholomew says.
Ideally, you should make sure the equipment is working before each procedure, Trosty says. At a minimum, make sure the equipment is working at the beginning of each day, he adds.
"You may need to calibrate it to make sure it’s measuring appropriately or reading appropriately," Trosty says.
A machine that is off a little can make a big difference, he emphasizes, especially when the machines monitor anesthesia or perform the surgery. You don’t want to discover that a vital piece of equipment, such as a radioisotope, isn’t working correctly in the middle of surgery, Trosty emphasizes.
"If it’s not working, tag it and get it out of the surgical suite, so it isn’t used by anyone else," he advises.
- Be aware of the potential for wrong site/ wrong patient surgery, particularly when you’re busy. Initial the surgical site, and have a time-out at the beginning of each procedure.
In the otorhinolaryngology study, two cases of the wrong patient being brought into the OR occurred in outpatient settings, and in both cases, the respondent commented that time pressure in a busy facility was a contributing factor, says one of the study’s authors, David W. Roberson, MD, assistant professor of otolaryngology at Harvard Medical School in Cambridge, MA, and associate in the department of otolaryngology and communication disorders at Children’s Hospital Boston.
The Joint Commission on Accreditation of Healthcare Organizations has requirements in place to avoid wrong site/wrong patient/wrong procedures, Trosty points out. The requirements address the marking of the surgical site and other areas.
"Have a time-out before surgery begins to perform a second check of the patient, the type of surgery, the part of the body operated on, and the location on the part of body," Trosty advises.
Many surgeons are asking patients to confirm the site as well as confirm who they are, notes Bartholomew.
- The perioperative and postoperative period is high risk. Risk factors for postoperative death may include narcotic use, developmental delay, and obstructive sleep apnea.
In the recent study, "errors in surgical judgment, scheduling patients in a facility that was not appropriate — e.g., a complex patient in an outpatient setting — technical errors and medical management during surgery were all high-risk areas," Roberson says.
Preoperative, intraoperative, and postoperative checklists help eliminate errors by keeping everyone focused on key issues of patient evaluation and identification, surgery sites, procedures, medications, and discharge instructions, Drake says.
In the immediate post-op period, skilled and trained staff must monitor the patient for the first signs of complications, such as breathing difficulties, bleeding, changes in vital signs, reactions to anesthesia and/or medications and level of alertness, she says.
In the postoperative period, it’s critical to ensure patients who received general anesthesia are breathing at a normal level and their oxygen saturation level remains correct, Trosty notes.
"There can be instances when the patients aren’t monitored correctly, and they may have been given too much anesthesia; or the patients have had a bad reaction, and that can affect oxygen coming in or carbon dioxide going out," he says. "That can have significant negative consequence, up to and including death."
Even location sedation needs to be closely monitored for potential complications or adverse events, Trosty says.
Staff should be adequately trained in cardio-pulmonary resuscitation and advanced life support, particularly in a freestanding outpatient surgery center, he advises. "If a patient should suddenly arrest or code, you need to make sure you have people there who are trained and can respond and that you have appropriate safety equipment and an emergency cart with appropriate equipment and medicines, to try to bring them back," Trosty says.
Discharge instructions are an important piece of avoiding safety risks, Drake emphasizes.
They tell the patient what medical regimen to follow at home over the next days and/or weeks, she says. "The instructions also should let the patient know the possible complications and alert the patient when to notify the doctor," Drake adds.
1. Shah RK, Kentala E, Healy GB, et al. Classification and consequences of errors in otolaryngology. Laryngoscope 2004; 114:1,322-1,335.