In the operating room, we use the phrase "patient safety" an awful lot - for good reason, too. Everything we do hinges on providing our patients with a safe surgical experience. We confirm their identity, surgical site, and laterality multiple times before rolling back, we position them for their procedures in ways least likely to cause nerve or pressure damage, we coordinate with various hospital departments and vendors to ensure we have all needed implants and supplies, and we work together as a team to confirm that our instruments and supplies are sterile prior to starting surgery. We also pause, prior to the incision, to observe the timeout, to confirm one final time that everything is correct - because our patient's safety is our number one priority.
Patient safety is both our priority and our taskmaster
We perform a multitude of tasks every single day, all designed to protect our patients from injury or error. We have policies and procedures that we follow, we have checklists to complete, and sometimes it feels like we even have checklists for our checklists. But even in the seeming redundancy of the questions that we ask and the checklists that we go through before we begin an operation, there's a much bigger goal in mind than just completing tasks and checking off lists. We want our patients to be safe, and we want to avoid a mistake. The undercurrent of every task that we complete is patient safety. Patient safety is the goal and the taskmaster. It's the undercurrent or driving force behind everything that we do.
Patient safety is determined by communication
Effective communication is fundamental to patient safety. There are other things that affect patient safety, too. Like compliance with policies and procedures, leadership engagement, and a culture of safety, where everyone is respected and empowered to voice concerns. But focusing on how we communicate is critical, because lack of communication is almost always listed as a root cause of error in wrong site surgeries.1,2
As a patient moves through the scheduling and surgical process, there are 5 critical intersections where effective communication is vital.
The Consent
While it's not our responsibilty as circulators to obtain the surgical consent, this is still a necessary part of the communication process. The consent represents communication between the surgeon and the patient. It signifies that the patient has been informed of their surgical procedure, the risks and benefits have been explained, questions have been answered, and the patient understands the surgery and expected outcome based on their conversation with their surgeon.
The consent also lets the OR know exactly what procedure we're going to be doing. The posted procedure on the surgery schedule is based off of the consent. The consent determines which preference card gets used to pull the case. The team in the room uses the surgery posting and the pref card to set up for the case, to make sure they have all necessary equipment and supplies, and to determine positioning.
When a consent is incorrect, we risk performing the wrong procedure, positioning the patient incorrectly, or not having the necessary equipment to perform the procedure. Sometimes it's simply a matter of confusion between what the patient says and what the consent says. This is usually easy to clarify, but it causes delays while we take the necessary time to ensure that we are doing the right surgery on our patient. Other times, it's a much bigger mistake: right side instead of left, or the entirely wrong patient or procedure. Attention to detail, confirming surgical site and laterality, and confirming patient identity with two patient identifiers is crucial in preventing a wrong-patient, wrong-site surgery.
Surgery Posting
When the decision is made to schedule surgery for a patient, the surgeon's office sends the information to the OR scheduler. Posting the case correctly, and clearly communicating any special needs for the case, is vital for the OR to be adequately prepared. I realize I'm speaking to surgeons and schedulers at this point, but, "Help us help you!" We can only be as prepared as the information we're given. This may sound like a news flash, but OR nurses and scrubs aren't mind readers, and it's dangerous to assume that staff will "know how I always do the case." The surgical posting is the surgeon's opportunity to communicate his or her needs for the case: positioning, vendors, implants, special suture or instruments, etc. This is also an opportunity to communicate any special needs the patient may have as well: hard of hearing, blind, non-English speaker, etc.
Having all of this information allows the OR to be fully prepared for the case. Coordinating vendor trays and implants, and having them ready for the case, involves preparation. Pulling cases takes time, and when a case isn't posted correctly, it causes delays when new items have to be pulled. If a special instrument set is needed for the case, it may not be sterile if that need wasn't communicated.
There's few things worse than having a patient asleep on the table, open, and suddenly realizing a necessary item isn't available for the case. Effective communication from the surgeon to the OR through the surgery posting allows us to be properly prepared for cases, reducing the risk of an avoidable error that could potentially harm our patient.
Pre-Op Checklist/Patient Interview
I'm bundling these together, because I generally review the checklist in the computer and then go interview my patient. So to me, they go hand in hand. The pre-op nurse initiates the completion of the pre-op checklist, but the OR nurse is also responsible for confirming the information. We interview our patient and confirm identity, allergies, procedure, and laterality. We double-check to make sure we have an H&P, that the consent has been signed, and that the procedure listed on the consent is the procedure the patient states is being done.
All of these steps require communication, primarily with the patient. There are times, however, that the patient is unable to be interviewed by the OR nurse. For example, a patient receiving a preoperative pain block receives anesthesia and they are unable to speak to the OR nurse when it's time to roll back. In instances like this, it's vitally important that the OR nurse communicate with the pre-op nurse to confirm that all information on the checklist is accurate and complete. The OR nurse is still responsible for confirming that the pre-op checklist is complete and addressing any concerns prior to rolling back.
Time Out
If there was ever a "10 Commandments of Surgery," observing the time out would be at the top of the list. It's a sacred step in the surgical process, and something that should never be rushed through, ignored, or skipped altogether. The time out is our last chance to make sure that we've gotten everything right. We confirm, as a team, prior to the cut, that we have the correct patient, the correct procedure, the correct side, and that all necessary items are available. And while, at times, it may feel like double work since we confirmed all of that same information on the pre-op checklist and in our patient interview - we're still human. We get distracted and prep and drape the wrong leg. We accidentally prep and drape for a carpal tunnel instad of a cubital tunnel. Side-specific implants are made for the patient, but the patient is consented for a right total knee and the company sent the implants for the left knee. (yes, I've seen it happen). Mistakes happen. And the time out is our last chance to catch those mistakes to prevent an error.
Patient safety is more important that the time it takes to pause and confirm that everything is correct. Properly performing a time out will not prolong a case, or cause delays in later cases, despite how certain members of the surgical team act at times. Patient safety is our priority. Effective communication through a proper time out involving the entire surgiecal team helps prevent an error and protects our patients and ourselves.
Handoff
Handing off care of the patient, either to the recovery room, ICU, or to another person in the OR is a time when communication is most critical - and a time when important information is likely to get left out.3 We're being relieved, and we just want to go home, so we tell the oncoming nurse the patient's name, yelling out, "No allergies!" as we run out the door and bolt for the time clock. Or, we're so done with the disasterplasty that we've been involved in, by the time we get to recovery or ICU, we can't even remember all of the important details that we need to pass on. I know what it's like; I've had days like that. But giving a good report, and handing off care to another provider, must be treated as an important part in the patient's care - not just another thing we have to do before we go home or move on to another case.
The handoff isn't specific to nurses, either. Every member of the surgical team can be relieved, even another surgeon can assume care of the patient, and everyone needs to know what's going on. It's critical that the handoff, or the transition of care, is detailed and complete. The chart can give you alot of information and history, but it can't tell you everything that has happened in the case - only the team in the room has that information.
Best practices state that the handoff should be standardized, that it should be as uninterrupted as possible, and that time should be allowed for questions and concerns. Generally, anytime we say "standardized" what we end up with is another checklist. But, the goal is a safe continuum of care for our patients by ensuring important information is passed on to the next caregiver. Remember, we're all human, and prone to forgetting. Any form that is used for the handoff is there as a memory aid, to assist with the transition of care, and to help prevent errors.
Effective communication is vital to patient safety, and to a successful surgical outcome
The consent, the surgical posting, the patient interview, the time out, and the handoff are all times when effective communication is critical. These interactions, either with the patient or about the patient, lay the foundation for a safe surgical experience. Don't overlook these opportunities, or discredit their value. Each of them is communicating information we need in order to safely care for our patients. And our patients are depending on us to get it right.
It's easy to get lost in the chaos and stress of the day-to-day. Take advantage of each opportunity to communicate, and recognize the benefit to your patient's safety when you prioritize effective communication.
Sources
You can listen to an audio version of this article through our Articles On-The-Go! Series here!
Comments