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 Authors point out that recently questions have been raised regarding the (SSC) and its true impact …show more content…
2012). This step relates to the (National Safety and Quality in Healthcare Service Standards, (NSQHS 2012). Standard five ‘Patient identification and Procedure Matching’ is a tool used to identify a patient and the matching of a patient to an intended treatment. The intention of this Standard is to ensure that consumers are correctly identified whenever care is provided and that they are correctly matched (NSQHS 2012). Risks to patient safety occur when there is a mismatch between a given patient and components of their care, whether those components are diagnostic, therapeutic or supportive (NSQHS). Failure in doing so the surgical team is at risk of overlooking this standard. The Australian College Of Operating Room Nurses (ACORN) Standards for Perioperative Nursing Australia 2016, ‘Accountability for practice standard’, principle 1.2 states the WHO SSC was ‘designed to improve the safety of surgical procedures’ & Principle 3.1 use the WHO checklist to identify patient risks preoperatively. The literature addressed in this review has confirmed that multiple factors impact on the successful implementation of the WHO SSC. Barriers of communication and the hierarchical nature of the operating theatre environment were to found to have detrimental effect on the completion of the time out and sign out components of the who checklist. Article Structure The article clearly presented a well-structured introduction and abstract which allowed for
With all of the possible problems that could occur during surgery, a wrong-site, wrong-patient mistake is one that should never arise. Nightingale Community Hospital (NCH) fully understands the importance of doing away with these errors and has set up protocol to work towards this goal. While the protocol is in place, it is not fully compliant with Joint Commission (JC) standards.
Use at least two patient identifiers when providing care. Double checking of ID bands and ID/Driver’s license of patient if possible. Using labels to mark all materials /items needed for the procedures. A two person check off procedure must be implemented. Items requiring labeling include: patient records, signed consents, and all assessments, diagnostic tests and x-rays. Also included should be any item that is needed for the procedure (blood products, devices, and equipment). Using a matching system, so that all items in the procedure area are matched to the patient. The matching system must be completed by a minimum of two staff members. These staff members should include a qualified staff member, nursing staff involved in the procedure, recovery room staff, and discharge staff.
Patient safety one of the driving forces of healthcare. Patient safety is defined as, “ the absence of preventable harm to a patient during the process of healthcare or as the prevention of errors and adverse events caused by the provision of healthcare rather than the patient’s underlying disease process. (Kangasniemi, Vaismoradi, Jasper, &Turunen, 2013)”. It was just as important in the past as it is day. Our healthcare field continues to strive to make improvement toward safer care for patients across the country.
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).
2. Verbal Order / Read Back elements: Goal is 100%. • This is so important to minimize any wrong information or orders misunderstanding, or even misinterpretation. The lack of full compliance increase the risk of wrong treatments, medications and the consequences could be major. Our institution compliance varied between departments, and was noticed that surgical and in specific orthopedic department was the least compliant with verbal order policy. The compliance in this department was 62%. Reasons for this non compliance include: a. Lack of pathways for specific medical problems, where standard orders are the acceptable route to minimize inappropriate orders. b. Timing of the verbal orders, specifically during the night, where most of non-compliance documented. c. Surgical and specifically orthopedic department have a significant trust between surgeon and staff, which lead to non-compliance. These elements should be addressed aggressively to avoid harm.
As the Joint Commission aims to nationally improve health care systems through health care organizations collaborations, it publishes recommended patient safety goals. As stated by the Joint Commission, “the first obligation of health care is to “do no harm””. The Joint Commission’s 2015 National Patient Safety Goals for hospitals include : Identify patients correctly; Improve staff communication; Use
Timing is everything when it comes to patient health outcomes. The purpose of this study is to provide a comprehensive review of the critical value reporting process critical results to the appropriate staff members according to the guidelines described in the National Patient Safety Goals (NPSG) of the Joint Commission Accreditation on Healthcare Organizations (JACHO). The Joint Commission has listed the following NPSG for 2015: identify patients correctly, improve staff communication, use alarm safely, prevent infection, identify patient safety risks, and prevent mistakes in surgery (The Joint Commission, 2015). A pathologist first introduced critical values by the name of Lundberg over 30 years ago. A critical value was viewed as an indication that the patient was in graved danger unless interventions were done to address the decline in health status (Plebani, M. and Piva E. (2010). The national patient safety goal that reflects the benchmark on our medical-surgical/Telemetry unit was staffing communication in reporting critical values. Our facility as a whole was at 73% compliance for staffing communication. Our hospital 's compliance goal for staffing communication is 90%. However, our unit is currently at 75% compliance. Various factors contribute to the timeliness and compliance of reporting critical values including work force, material and methods, and equipment.
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.
* Hand washing is the most important method of preventing the spread of infection by contact (Ayliffe et al 1999). The Nottingham University Trust Policy on Hand Hygiene (2009) states that there are three types of hand hygiene, the first is ‘routine hand hygiene’ which involves the use of soap and water for 15 – 20 seconds or the application of alcohol hand rub until the hand are dry. The second is ‘hand disinfection’ which should be used prior to an aseptic procedure by washing with soap and water and applying alcohol hand rub afterwards. The third is ‘surgical hand washing’ which is the application of a microbial agent to the hands and wrists for two minutes. In addition to which a sterile, disposable brush may be used for the first surgical hand wash of the day although continued use will encourage colonisation of microbes. The third example is the most appropriate to any O.D.P undertaking the surgical role as it is the best way for the surgical team to eliminate transient flora and reduce resident skin flora (World Health Organization 2010). The first and second are important to any O.D.P undertaking any other role within the Operating Department as this is the best way to reduce the transient microbial flora without necessarily affecting the resident skin flora
UP.01.03.01 requires a time-out before the start of the procedure. The Site Identification and Verification policy describes the time-out process however the policy falls short of fully meeting the intent of this standard. EP 2 describes which team members must participate in the timeout, EP 3 requires a time-out before each procedure when two or more procedures are being performed, and EP 5 requires documentation of the time-out. These 3 elements are missing from the hospital policy/process and therefore revisions to the process/policy are necessary to include these 3 elements. Nightingale’s Safety Report reveals increasing compliance (nearing 100%) with the time-out process, however as mentioned above, EP 5 requires documentation of the process. In addition to the policy revision, I recommend the development of a unique form which will be used to document
"To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (Jointcommission.org, 2015). These requirements are regimented in the National Patient Safety Goals and are enforced via surveys and internal inspections to ensure that healthcare institutions abide by the safety mechanisms put in place to facilitate the optimal patient outcomes and environments.
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 Joint Commission focuses on certain goals each year. For patient safety and positive outcomes, hospitals are required to follow certain standards. National Patient Safety Goals were established in 2002 to help identify areas of concern with patient safety. This group is made up by a panel of experts including nurses, doctors, pharmacists and many other healthcare professionals. They advise the Joint Commission on how to address these different patient safety issues. Two goals to be discussed are improving the accuracy of patient identification and medication safety. To improve patient
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