Joint Commission warns about OR sentinel events
First came the report from the Washington, DC-based Institute of Medicine that estimated medical errors kill at least 44,000 people in U.S. hospitals each year and possibly as many as 98,000. Next, the Chicago-based American Hospital Association (AHA) added its stamp to the current emphasis on patient safety. The AHA Web site (www.aha.org) now offers a section on reducing medication errors that includes resources and safety strategies from hospitals. At press time, the AHA also planned to post a model event reporting system for medical errors on the Web site.
Topping off the growing emphasis on patient safety, the Joint Commission on Accreditation of Healthcare Organizations has issued a Sentinel Event Alert on operative and postoperative complications. (For information on how to access the Alert, see the resource box, p. 57. For definition of a sentinel event, see box, above.)
Nonemergency procedures in 90% of cases
Since the agency began tracking sentinel events about four years ago, it has reviewed 64 cases related to operative and postoperative complications.1 The agency reports 84% of the complications resulted in patient deaths, and 16% resulted in serious injury. Ninety percent of the cases involved nonemergency procedures. (For details of the complications, see box, p. 56.)
In its alert, the Joint Commission listed root causes of the operative and postoperative complications, as well as risk reduction strategies that can prevent such complications. (See story on risk-reduction strategies, p. 57.) Here are the root causes that apply to the same-day surgery setting, along with tips from your peers on how these areas can be addressed:
• Inadequate communication among caregivers. "Most of the time when a problem occurs, it’s a miscommunication between physicians and other people, or even between staff members," says Vicki Sullivan, RN, CNOR, administrative director of Quad City Ambulatory Surgery Center in Moline, IL. For example, a physician might misunderstand the order of the surgical procedures. To avoid that problem, Quad City posts the schedule, and staff ensure the surgical permit is posted as the patient is presented to the physician.
• Failure to follow established procedures. Don’t assume that your staff are following your facility’s procedures; instead, find out for yourself, SDS managers advise. At Southeastern Surgery Center in Tallahassee, FL, managers are required to spend about one hour per week auditing their departments to ensure that the policies for proper procedure verification are being followed, says Susan Kizirian, MBA, executive director. The managers make sure that the caregivers are verifying the correct patient, correct surgical site, and correct procedure.
"What I tell each manager is that when staff tell you they’re sick and tired of it, you’re doing your job," she says.
• Necessary personnel not available when needed. While most same-day surgery programs interviewed for this story said their staffing is adequate, several added that the emphasis on cost-containment in outpatient surgery can lead to staffing problems at some facilities.
"I definitely can see how that can happen, because dollars always count and that’s the first place someone always wants to cut: staff dollars," Sullivan says. However, staffing isn’t the most effective place to cut for financial savings, she emphasizes. "If you don’t have adequate staff, then you’ll have corners being cut and inappropriate people working in some spots."
• Incomplete preoperative assessment. Have two or three people perform the preoperative assessment to ensure you obtain all the critical information, Sullivan suggests. "Sometimes, patients don’t want to burden a doctor. They feel intimidated by a doctor, but then they talk to a nurse who’s friendly and open, and they’ll tell her things they don’t want to bother the doctor with," she says. "So sometimes nurses pick up a lot more than the physicians do."
This tactic works especially well with older patients because they often enjoy talking with nurses and provide additional information, Sullivan adds.
And just as a pilot goes through a checklist before flying a plane, your staff should go through a checklist to ensure all the critical items, including the history and physical, are on the chart before the patient goes to the OR, Kizirian emphasizes. "The reason those items are on a pre-op checklist is because they’re critical to ensuring patients have good outcomes."
At Southeastern Surgery Center, the pre-op nurse checks off the items on the list, and the circulating nurse double-checks the list before the patient goes to the OR.
• Deficiencies in credentialing and privileging. Simply reading about deficiencies in credentialing and privileging is enough to raise the blood pressure of many same-day surgery managers. Ann Geier, RN, MS, CNOR, chief operating officer of Medicus Surgery Center in Anderson, SC, says, "With liability of credentialing and privileges, nothing like that should happen anywhere."
At Medicus, physicians who have privileges at the hospital still undergo an extensive check before they are credentialed to perform procedures at the surgery center, she says. "We verify training, what type of training they received, where they trained."
Medical schools and residency program must verify whether the surgeons were taught the surgical procedures in their programs. If not, the center contacts the program that performed the training. "In this day and age, it behooves everyone to have that in place," Geier advises.
And same-day surgery programs face additional issues, Kizirian points out. How many hands-on procedures must surgeons perform before they can do procedures alone? How long a class do they have to attend? How many times must they be precepted before they can perform the procedure alone? "This will continue to be an issue due to technology and new ways of doing procedures," Kizirian says. (For more on credentialing for new technology, see Same-Day Surgery, March 2000, p. 25.)
• Inconsistent postoperative monitoring procedures. Provide training and use a postoperative checklist to ensure patients aren’t discharged until they meet all criteria, including postoperative education, Kizirian advises.
Inconsistent post-op monitoring can be related to a staffing deficiency, Sullivan points out. "If you don’t have enough people to take care of your patients, problems go unnoticed and aren’t addressed."
• Failure to question inappropriate orders. Empower your staff so they are comfortable questioning orders that appear inappropriate, Sullivan emphasizes. Because Quad City performs the same procedures routinely, an out-of-the-ordinary order stands out, she says. "Employees are quite comfortable questioning that. They’ve been empowered to make those professional judgmental decisions."
Be sure to educate new staff persons about questioning orders, Kizirian emphasizes. "We cover the types of orders they’re given and we say, If it doesn’t make sense to you, ask.’"
In the same-day surgery setting, staff need to understand that a wide variety of adverse events can happen at any time, Sullivan emphasizes. "Those who think, It will never happen to me,’ are the scary ones. You do have to be prepared for all those things."
Reference
1. Joint Commission on Accreditation of Healthcare Organizations. Operative and post-operative complications: Lessons for the future. Sentinel Event Alert 2000; 12. Web site: www.jcaho.org.
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