Quality And Culture Of Safety

The Safe Surgery Save Lives initiative undertaken by the World Health Organization (WHO) in 2008 focused on implementation of a surgical checklist. The safety checklist requires the surgical site be checked during the check in process as well as during the surgical time out.

In 2003, as an outcome of all the sentinel events reported to the Joint commission lead to the creation of the “The Universal protocol for preventing wrong site, wrong procedures, and wrong person surgery” (Mulloy & Hughes 2008). So, one of the ways that could have potentially prevented the situation from happening at the first place was implementing the universal protocol procedure. According to the protocol the conduction of proper pre as well as post-operating procedures are extremely mandatory. Therefore, by enforcing a standardized routine pre-operating procedure such as verifying the patient as well as the correct site for the procedure, by having the medical staff or preferably the physician marking the operating site with his or her initials before the surgery will be an effective preventive measure (Mulloy & Hughes 2008).

In 2008, it was estimated that “medical errors total more than $19.5 billion” (Andel, 2012, p. 12). It is important to address and solve this problem at this time because the National Quality Forums (NQF) “never events” considers such events. Never events are events that occur that should have never occurred in the first place. Reducing and eventually eliminating wrong site surgeries will help improve patient safety in the operating room and become a leading example in improving patient safety in all aspects of healthcare.

Each year medical errors cause more than 400,000 American deaths and at least 10-20 times that number experience serious harm. Researchers say that is equivalent to “three 747 airplanes crashing each day.” Medical errors rank as the third-leading cause of death in America. Therefore, patient safety is a national concern.

Over the last several years, a wide variety of health care organizations have been facing a number of challenges. This is because of pressures associated with: rising costs, increasing demands and larger numbers of patients. For many facilities this has created a situation where patient safety issues are often overlooked. This is because the staff is facing tremendous amounts of pressure, long hours and more patients. The combination of these factors has created a situation where a variety of hospitals need to improve their patient safety procedures. In the case of Sharp Memorial Hospital, they are focused on addressing these issues through different strategies. To fully understand how they are able to achieve these objectives requires looking at: specific ways the organization has responded to the crisis in medical errors, their definition of patient safety, the causes of errors, systematic barriers and transformations that have been adopted. Together, these different elements will provide the greatest insights as to how the facility is coping with the crisis in patient safety.

At least half a million deaths per year could be prevented with effective implementation of systemic improvements in operating rooms. Specifically, multiple studies have found implementing the use of the WHO Surgical Safety Checklist would significantly reduce surgical morbidity and mortality due to surgical errors.

Mistakes in surgery such as wrong-site, wrong-patient, or wrong procedure occur all to often. These events are termed “sentinel events.” A sentinel event can be described as an accident or mistake that occurs in a hospital or other healthcare setting. These events can cause serious injury or death to a patient. Over the past few decades, major organizations such as the Joint Commission and the World Health Organization have put forth policies to try and decrease the incidence of these mistakes. In 2004 the Joint Commission developed the Universal Protocol. Under this protocol the patient must be identified, the surgical site must also be identified and needs to be marked, and lastly it states that there needs to be a time-out before any procedure occurs. This time out allows the surgical team an opportunity communicate and verify the procedure, the patient, and the correct surgical site. Shortly after this protocol was released, the World Health Organization released a similar protocol, but on a larger scale. This was the “Safe Surgery Saves Lives” campaign. This checklist was spread world wide and included three parts to ensure patient safety in all portions of the surgery; the sign-in phase, the time-out, and the sign-out phase.

Patients are at heightened risk of complications while undergoing surgery. The use of a checklist for surgical safety has been utilized to lower these rates of complications. This paper was developed to respond to the question: When health care professionals implement a surgical safety checklist, compared to regular procedure without use of a checklist, do incidence of complications in patients decrease during hospital stay? CINAHL, Pub Med, and the Cochrane Library databases were searched using keywords: checklist, patient safety, surgery, adverse events, and complications for credible publications and retrieved five relevant

Human error theory explores human factors and ergonomics, which contribute to the implementation and design of health and safety measures in healthcare. The theory identifies the effect of medical errors by healthcare providers cause significant risks to the health and safety of patients. It explains human errors in terms of contributory factors that prevail in a person's performance, immediate environment, and the broader organizational level. Human errors that influence performance are identified in broader categories of lapses, mistakes, or slips. To mitigate this, the research identifies the establishment of safety and health standards in organizational culture and structure to change individual behavior and organizational behavior.

The IOM’s report “To Err is Human: Building a Safer Health System” shocked the health care world and made change necessary. “To Err is Human: Building a Safer Health System” released information that reported that tens of thousands of Americans were dying each year from errors (IOM, 1999). Patient safety moved to the forefront in healthcare like never before and directives were discussed to put quality as a

In accordance with the World Health Organisation (WHO 2008) checklist and Local trust policies, a team briefing was held before the day’s list started. The checklist is part of a second Global Patient Safety Challenge initiative entitled ‘Safe Surgery Saves Lives’, aimed at reducing the number of surgical deaths worldwide and was launched in June 2008. This not

The Article ‘Barriers to staff adoption of a surgical safety checklist’, by Fourcade et al. 2012, seeks to identify the many barriers which effect the implementation of a surgical checklist and to develop best use of strategies. The purpose of the article is to identify ways to improve factors which influence the successful implementation of the World Health Organisations (WHO), Surgical Safety Checklist (SSC). The article identifies that the use of the SSC implemented by WHO 2008, has become increasingly well-known and is associated with a substantial decrease in postoperative complications and mortality rates (Fourcade et al. 2011).

The WGU nursing program helped me in developing my professional definition of quality and safety by enlightening my understanding of root cause analysis, and system failures. The IHI course was an eye opener in my understanding of quality improvement, and the processes required to enhance safety and quality improvement. The courses that really assisted me in my definition include, the Organizational Systems and Quality Leadership, the Leadership and Professional Image, and Professional Roles and Values; and the Evidence-Based Practice and Applied Nursing Research.

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

Mistakes and carelessness by health care providers in an operating room lead to unintentional retention of surgical objects after invasive procedures on patients. According to a study conducted by the Pennsylvania Patient Safety Advisory (2009), retained surgical items were a hundred times more likely to occur in procedures with counting discrepancies. The failure to account for all items such as catheters, sponges, sharps, and instruments caused serious patient harm and called for additional medical