Patient Safety

1. Patient Safety Marianne Cosgrove, CRNA, DNAP, APRN

2. Human Error • An inappropriate or undesirable human decision or behavior that reduces or has the potential for reducing: • effectiveness • system performance • safety

3. Healthcare Errors • Non-intended healthcare outcomes resulting from a defect in the delivery of care to a patient • Errors of commission • Errors of omission • Errors of execution • These occur on a daily basis in the OR!

4. To Err is Human • A report published by the Institute of Medicine (IOM) in 2000 • Found that: • Errors will happen • Some errors are predictable • Some errors are preventable • Causation is typically multifactorial

6. AHRQ (Agency for Healthcare Research and Quality) • Follow-up study to IOM report over 3 years (2000, ’01, ‘02) • Noted that the IOM report represented the “tip of the iceberg” • Underreporting is an issue • 195,000 deaths/year due to preventable error!

7. Error • May be active (the person makes a mistake) • May be latent (the person is dealing with a system which has a hidden deficiency) • A.K.A. “resident pathogens”

8. Reason’s “Swiss Cheese Model”

9. Critical Incident (CI) • An accident • An event that could have (if not quickly resolved) or did lead to a major complication.

10. CI at HSR - 2004

11. Error and anesthesia • “Anesthetists work in a risky environment where one small mistake can have catastrophic results.” • Human error can never be eliminated, however… • it can be predicted • systems can be designed to minimize mistakes

12. Set-ups for error • Use of complex machinery • Variability in patient • disease • response to anesthetics, interventions • High degree of uncertainty • Interventions are risky • Unfamiliarity with setup

13. “Look-alikes” vasopressin and atropine metoprolol and rocuronium

14. The front of the medication drawer @ HSR Note the color similarity of neostigmine (behind glycopyrrolate) and lidocaine 1%

15. Set-ups for error • OR environment • High stress • Multiple personalities • Cramped working space • NOISE

16. Human factors leading to error • Lack of knowledge • Inadequate communication amongst team members • Haste • Distraction (iPhones, BlackBerries!) • Fatigue • Anxiety • Failure to perform normal checks (machine, pt chart)

17. Anesthetists work in a risky environment where one small mistake can have catastrophic results

18. Anesthesia-related factors associated with CIs • Inadequate trainee supervision • Drug misadventure (commonly OD) • Airway obstruction • Aspiration • Insufficient monitoring • Production pressure • Insufficient information • Task density too great • Poor communication (between pt and provider or among providers)

19. Modalities for increasing safety • SLOW DOWN • Check, and check again • “forcing functions” • Tinting gtts with dye • Physical barriers to use

20. Infection • HANDWASHING • Gloving/changing gloves frequently • Safe injection practices • Cleaning equipment between patients • Pronovost’s landmark study (NEJM ‘06) • Development of “checklist” for central line insertion • Catheter-related bloodstream infection rate dropped to nearly zero% • Pronovost checklist: • HANDWASHING • Full barrier precautions • Chlorohexidine scrub • Avoidance of femoral site • D/C of line ASAP!

22. Infection Control • 4-5 thousand people /year die from Hep B/C • 250 HCW die annually from HBV • The virus is most efficiently transmitted by blood exposures • Immune globulin not effective in prevention • 1992 OSHA required vaccinations available to HCW free of charge for HBV.

23. Outbreak in Nevada/Arizona Endoscopy Center/Oncology Clinic-in the news Hep B/C 40,000 patients are currently being tested Facility closed/practitioners lost licenses. Infection Control

24. Infection Control • CDC • Policies aimed at protecting the public • Recommendations, not mandatory • OSHA • Standards MUST be followed • Required personal protective clothing and equipment • Also required: • Hepatitis B vaccinations, work practice controls, medical surveillance signs/labels, annual training • Violations carry up to $70,000 fines for EACH occurrence

25. Exposure Prone Procedures Digital palpation of a needle in a body cavity Simultaneous presence of a needle and finger in area with poor visibility/confined area Highest Risk- NOT US ! BUT….. Infection Control

26. Infection Control • What do I do if I get exposed • Post exposure Management • OSHA standard • Facility must have program in place to provide post exposure testing, counseling, monitoring and surveillance • Patient exposed due to HCW will receive the same care • Medical records • Kept for 30 years beyond the duration of the employment

27. What to do if you are exposed Wash with soap and water Report Follow guidelines Report to occupational health clinic Infection Control

28. Tier 1= Standard Precautions Universal precautions Treat bodily fluids as if all are infected Wash hands before and after all contact** Wear gloves and other PPE when necessary Used needles and syringes in puncture resistant containers Do not recap needles Infection Control

29. Tier II=transmission based precautions Airborne Precautions Droplet nuclei 5 micrometers or smaller Wear special mask Reverse isolation room Droplet precautions larger than 5 microns Wear a mask within 3 feet of patient Infection Control

30. TB Delay procedure if possible Inform all staff Patients should wear masks outside the isolation area Anesthesia providers should wear mask (N-95) Use bacterial filter between patient and breathing circuit Recover in negative pressure room-PACU Infection Control

31. Infected patients in the OR Decrease traffic Use disposables All re-usable equipment must be sterilized Personal items should remain outside the OR Patients on contact isolation MRSA VRE Impetigo Herpes Viral conjunctivitis Infection Control

32. “ Outbreaks of viral and bacterial infections have been traced to contaminated multi-dose vials” ASA Recent study showed that 38% of anesthesia providers admitted to re-using syringes/needles on more than one patient Infection Control

33. Administration of drugs and solutions Strict aseptic technique Clean stopper with alcohol Sterile syringe and access devise If this is not done ,treat the vial as single use Patient safety outweighs cost savings No recapping of needles Needles and syringes are single use Needle to test regional block- single use Infection Control

34. Administration of drugs and solutions cont. Do not use bags or bottles of IV fluid as a common source of supply for multiple patients Clean amps with alcohol before breaking Stopcocks and injection ports are major sites of contamination Infection Control

35. Antibiotic protocol in OR * most commonly used ABX in HSR OR ***Document start time as time of administration: MUST BE PRE-INCISION!!*** • cefazolin *- Start within 1 hour of incision; bolus over 3-5 mins • vancomycin *- Start within 2 hours of incision; infuse slowly in 250 ml 0.9 ns or D5W • clindamycin - Start within 1 hour of incision; infuse over 15 mins • gentamicin - Start within 1 hour of incision; infuse over 30 mins • levofloxacin - Start within 2 hours of incision; infuse over 30-60 mins • cefotetan - start within 1 hour of incision; bolus over 3-5 mins

36. Infection Control • A few more notes on infection • Marker on IV bags • Tape on IV poles • Anesthesia machine • Gloves and your pen • Traffic patterns • Unrestricted=traffic not limited • Semi-restricted=traffic limited • Scrubs and hair covered • Restricted=hats and masks • OR suites and sterilization areas • Limited traffic • Enter from scrub room door

37. Communication • Some studies indicate 70 to 80 percent of medical errors are related to interpersonal interaction issues. • It has been noted that in 63% of sentinel event occurrences, communication breakdown is the leading root cause. • Poor communication has also been identified as the primary factor of both medical malpractice claims and major patient safety violations, including errors resulting in patient death

38. Patient identification Time out SBAR Hand offs Communication

39. Communication • Originating from the nuclear submarine service, SBAR stands for: • S - Situation: What is happening at the present time?B - Background: What are the circumstances leading up to this situation?A - Assessment: What do I think the problem is?R - Recommendation: What should we do to correct the problem?

40. Communication • The "time out" occurs when the patient arrives in the operating room. • All members of the operating room team must cease all activity and focus their attention on the patient. • The first member of the team  presents their pertinent information relating to the ensuing surgical procedure, the patient's name and medical record number

41. Communication • Time out: Circulating nurse • Patient’s name and ID# • States the type of surgery to be performed • The site of the surgery which has already been marked prior to entering the O.R.  • Antibiotic, if required, is given • The cascade reporting continues until all involved in the surgery have voiced their respective obligations or concerns.

42. Heat (Ignition source) Lasers Electrocautery Drills Light sources Oxidizers O2 N2O Fuel ETT Sponges Drapes Hair Prep solutions Fire Triad Fire Safety

43. O2 rich mixtures Any concentration above 21%=OEA N2O Endotracheal tube PVC Laser tube Nasal O2 Fire Safety

44. head/neck surgery under monitored anesthesia care has emerged as a high-risk setting for operating room fires; burn injuries represent 20% of monitored anesthesia care-related malpractice claims 95% of which involved head/neck surgery. Curr Opin Anaesthesiol. 2008 Dec;21(6):790-5. Fire Safety

45. Fire Safety • Airway fires • Remove the ETT • Stop the flow of airway gases • Remove flammable materials from the airway • Pour saline into the airway • Non-airway fires • Stop the flow of O2 • Remove burning or flammable materials • Extinguish fire

46. fire safety videos http://www.apsf.org/resource_center/fire-safety-video.mspx

47. FROM: Transfer from stretcher to the OR table Table or bed not locked Open side of the table unprotected Safety belt not on Lack of vigilance Family sues in operating room fall Matriarch suffered a fatal head injury January 29, 2008 Moments after undergoing surgery to replace a broken hip, an 86-year-old Dorchester woman fell from an operating room table at Boston Medical Center, causing a massive head injury that killed her a week later, her family said in a lawsuit filed yesterday. Falls NEVER TURN YOUR BACK ON A PATIENT!!

48. Production Pressure Rushing leads to error!

49. Production Pressure Documented events due to production pressure include: • inadequate evaluation • unidentified contraindications to surgery • Some causes include: • A need to work agreeably with surgeons • To avoid delaying cases • To avoid litigation • Due to pressure by surgeons to proceed with cases instead of cancelling them. • to hasten anesthetic procedures. (Some aspects of production pressure were perceived differently by those reimbursed by fee-for-service versus those paid by salary). • Time is money

50. Production Pressure, cont’d • CONCLUSIONS: Production pressure from internal and external sources is a reality for many in anesthesia and is perceived in some cases to have resulted in unsafe actions being performed. Anesthesiology. 1994 Aug;81(2):488-500. Production pressure in the work environment. California anesthesiologists' attitudes and experiences. Gaba DM, Howard SK, Jump B. Department of Anesthesia, Stanford University School of Medicine, California.