Safe Surgery Saves Lives Winnipeg Regional Health Authority April 2010 Operating Room Nurses Association of Canada Canadian Anesthesiologists’ Society Royal College of Physicians and Surgeons of Canada

Safety Stories Example: aviation tragedy  Korean Airlines Cockpit culture stopped the first officer (from alerting the pilot to asserting and arguing) about the imminent danger. Suggestions and clues are not clear messages. An example from your facility where the lack of communication was a risk for patient safety?  Close Calls?  Actual Adverse Event?

Surgical Safety is a Serious Issue Canadian Adverse Events Study (Baker et al. 2004)  More than 50% of adverse events involved surgery. The Healthcare Insurance Reciprocal of Canada reports that since inception (20 years, with most claims occurring in the last 7-8 years).  Surgical claims account for $27 Million, 40% could have been prevented with the checklist or approximately $10 Million.  Claim types: 210 retained foreign body; 94 wrong body part; and 9 wrong patient.

WHO Safe Surgery Saves Lives Meeting Geneva

The Faces of Harm

Evidence that checklist works

The Checklist and Communication

The WRHA Surgical Safety Checklist

Adapted from WHO and CPSI – Surgical Safety Checklists Tool to promote patient safety in the perioperative period Intended to give teams a simple, efficient set of priority checks for improving effective teamwork and communication. Intended to encourage active consideration of the safety of patients in every operation performed. Includes elements of other patient safety initiatives for example Safer healthcare now! VTE, SSI, and Time-out

What issues does this checklist address? All important safety elements are reviewed by ALL OR teams, for ALL patients, at ALL times Promote teamwork and communication –Communication is a root cause of nearly 70% of the events reported to the Joint Commission from Preparedness for the unexpected Promotes an environment that allows anyone on the team to speak up if patient safety is at risk. –Correct patient, operation and operative site –Safe Anesthesia and Resuscitation –Minimize the risk of infection

Doors closed? Checked!

Findings published on January 2009

Strengths of the Surgical Safety Checklist Deployable in an incremental fashion Supported by scientific evidence and expert consensus Evaluated in diverse settings around the world Ensures adherence to established safety practices Minimal resources Minimal resources required to implement a far- reaching safety intervention

“The estimate that up to 23,000 people died in 2004 in Canadian hospitals because of preventable adverse events is staggering. Checklists have been used in aviation to standardize and increase the reliability of systems.” “One wonders whether such checklists would have been introduced much earlier in medicine if surgeons shared the fate of their patients, as pilots share that of their passengers.” Adrian Boelen, retired pilot, Dorval, Que The View from Aviation

Objectives of Safe Surgery 1.The team will operate on the correct patient at the correct site. 2.The team will use methods known to avoid harm from the administration of anesthesia, while protecting the patient from pain. 3.The team will recognize and effectively prepare for life threatening loss of the patient’s airway or respiratory function. 4.The team will recognize and effectively prepare for the possibility of high blood loss 5.The team will avoid inducing any allergic or adverse drug reaction known to be a significant risk for the patient.

6.The team will consistently use methods known to minimize the possibility of surgical site infection. 7.The team will work to avoid the inadvertent retention of instruments or sponges in surgical wounds. 8.The team will secure and accurately identify all surgical specimens. 9.The team will effectively communicate and exchange critical patient information for the safe conduct of the operation. 10.Hospitals and public health systems will establish routine surveillance of surgical capacity, volume, and results.

The Checklist in Canada CPSI in collaboration with the University Health Network in Toronto partnered with the following organizations to adapt and implement the checklist:  Accreditation Canada  Canadian Anesthesiologist’s Society  Canadian Association of Pediatric Health Centres  Canadian Medical Association  Canadian Nurses Association  GreenDot Global  Nova Scotia Department of Health  Operating Room Nurses Association of Canada  Ottawa Heart Institute  Patients for Patient Safety Canada  Regina Qu’Appelle Health Region  Royal College of Physicians and Surgeons of Canada  Society of Obstetricians and Gynecologists  Suresurgery  University of Calgary

Why should your hospital adopt it? Significant commitment needed, but … Insignificant costs to implement yet there is clear evidence of improved safety Issues and omissions are being picked up! Takes 3-4 minutes but can save time over the course of a day A great team-building opportunity! You will be a leader in patient safety in Canada and the world What is required to implement?: Ongoing vigilance A champion (or better, champions) at all levels! Commitment from senior management and the board

Completion of the Checklist Verbal tool. Not intended to be part of the patient’s health record. Value is not reflected in the completion of a form. Important to avoid the phenomenon of “tick and flick”. Responsibility for implementing and ensuring adherence to all components rests with one or more representatives from surgeon, anesthesiologist, and nursing. Responsibility to carry out the checklist lies with ALL members of the team. Every team member must feel comfortable in initiating the process.

Patient Awareness Education The nurse in the preoperative area shall review the purpose of the Surgical Safety Checklist with the patient during the preoperative assessment. Information reviewed with the patient should not be new information as all of the elements of the checklist should have been provided to the patient during the Informed Consent process.

Checklist is divided into three (3) components:  Briefing;  Time-Out; and  Debriefing Items on the Checklist that are not applicable to the procedure being performed are not required to be completed. A lead has been designated for each component as indicated on the Checklist. Components of the Checklist

At a minimum, requires presence of anesthesiologist and nursing. Performed before induction of anesthesia. Performed with patient awake/participation. Refusal of patient to participate requires documentation. Briefing

Verbal confirmation with the patient:  Identity using two patient identifiers;  Consent for surgery;  Type of procedure planned; and;  Site (side and/or level of surgery). Site marked/not applicable  Confirm surgeon performing the surgery has marked the surgical site according to Policy

Briefing (cont) Allergies/Precautions  Does the patient have any known allergies? If so what are they? Latex allergy precautions required.  Is the patient on any specific infection control precautions? If so what? VTE prophylaxis  Is the patient receiving/to receive chemical VTE prophylaxis?  Is the patient receiving/to receive mechanical VTE prophylaxis?  Confirm TEDs/SCDs have or will be applied as per surgeon request &/or hospital policy.

Equipment, instrument(s) and/or implant(s) concerns  Equipment:  Confirm availability of special equipment required;  Confirm intended position; and  Discuss any problems with equipment.  Instruments  Confirm availability of instruments;  Nurse verifies sterility indicator/integrator; and  Any particular concerns.  Implants  Confirm availability of implant(s) required; and  Confirm availability of various sizes that could be used. Anesthesia safety checklist  Confirm anesthesia equipment safety check has been completed in accordance with local/departmental policies. Briefing (cont)

Difficult Airway/Anesthesia Risk?  Confirm airway equipment is available; and  Confirm if difficult airway anticipated or likelihood of pulmonary aspiration of gastric contents. Risk of > 500ml of blood loss?  May include PT/PTT/INR concerns;  Medications or morbidities that may lead to complications and any intention to transfuse blood products; and  Confirm if blood products are required and if they are available. Postoperative destination  Confirm postoperative destination and any potential for changes.

AT THIS POINT THE BRIEFING IS COMPLETED AND THE TEAM MAY PROCEED WITH INDUCTION OF ANESTHESIA, FOLLOWED BY POSITIONING, PREPPING AND DRAPING.

Time-Out

Time-out At a minimum, requires surgeon, anesthesiologist, and nurse(s) to be present. Performed after induction, prepping/draping immediately prior to surgical incision. Completed in accordance with WRHA Policy “Correct site, correct procedure and correct patient for surgical procedures (identification of) # Team members are identified  Team members are identified by name and role. If previously introduced, it is not required to repeat this step. Team verbally confirms:  Correct Patient;  Correct Procedure; and  Correct Site.

Antibiotic prophylaxis given within the appropriate time frame.  Confirm antibiotic prophylaxis has been given within 60minutes (2 hours for Vancomycin and Fluoroquinolones) and when next dose will be given;  If not given, give before incision;  If administered, when is next dose due; and  Consider antibiotic circulation time and duration of tourniquet time. Essential imaging displayed?  Confirm essential imaging has been displayed and is displayed correctly. Team communicates anticipated complications. STOP! Does everyone agree we are ready to go?

AT THIS POINT THE TIME OUT IS COMPLETED AND THE TEAM MAY PROCEED WITH THE SURGERY

Debriefing At a minimum, requires surgeon, anesthesiologist, and nurse(s) to be present. Performed during or immediately after wound closure before the patient is transferred from the operating room. Should be initiated when informing the surgeon that “Count is Correct” Nurse verbally confirms with the entire team  Confirmation of procedure performed as stated by surgeon;  Verbal confirmation of specimen details;  Verbal confirmation of surgical count; and  Identification of equipment problems. Surgeon reviews with the entire team  Summary of important intra-operative events  Indicate management plans

Anesthesiologist review with the entire team  Summary of important intra-operative events  Confirm blood/fluid loss  Recovery plans including concerns/issues related to postoperative care  Confirm normothermia Is there anything we could have done better?  Must be asked for each procedure  Team members must respond with either a negative or a specific answer to the question  Consider three (3) questions when answering:  What did we do well?  What did we learn?  What could we do better/do differently? Debriefing (cont)

HANDOFF TO PACU/RR, NURSING UNIT OR ICU SAFETY CHECKLIST IS NOW COMPLETE

How not to complete the Surgical Safety Checklist

Completing Surgical Safety Checklist

Completing Surgical Safety Checklist – Complex Case

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