From Blame to System Failures
The evolution of terms: medical error to adverse events to patient safety incident means that there has been a shift from attributing blame on a single person, to recognizing that safety often resides in healthcare system failures.
Adverse events are not typically attributed to poorly skilled OR team members but to the failure of patient care delivery processes (Clendinneng, 2020).
Teamwork and Safety
- Teamwork is a subtle factor contributing to safety
- Non-technical skills needed by OR Nurses
- Scrub Practitioners’ List of Intraoperative Non-Technical Skills (SPLINTS)
- NTS can be taught and learned through role modelling, practice, and constructive feedback (Flin et al., 2014)
AORN (2017).AORN and The Joint Commission Team Up For Time Out Super Heroes
Example of SPLINTS
Non-Technical Skill: Situational Awareness
Non-Technical Skill: Communication and Teamwork
Non-Technical Skill: Task Management
🧠 Graded Activity
In Blackboard, complete the Graded Activity: Reflection
Focusing on Safety
- A positive way to look at safety is to determine what goes according to plan.
- A proactive approach to understanding what goes right helps enforce safety.
- ORs with systems processes in place, team members who communicate, collaborate, and share goals of safe outcomes, have fewer adverse events.
- Novice OR nurses must pay attention to positive team behaviours and actions that result in seamless, safe, patient outcomes. When errors are made, learn from personal and others’ mistakes. Debrief with a senior nurse in the room to understand what went wrong and how to avoid future mistakes.
Case Study
CMPA (2021). Proactive steps to ensure safe joint surgery
Case Excerpted from Canadian Medical Protection Agency (2021).
In Canada from 2018-2019, over 137,000 hip and knee arthroplasty surgeries were performed. Even routine elective joint surgeries harbor patient risks, as seen in the 198 medico-legal cases during that time when most were elective surgeries.
Wrong-side surgery and team communication
Surgical procedures with harmful outcomes to patients had a common theme which was the breakdown in information exchange and communication within the surgical teams, primarily due to distractions.
Case scenario: A patient undergoes surgery on the wrong hip
A woman provides informed consent to undergo hemiarthroplasty of the left hip. On the day of surgery, the surgeon meets with the patient pre-operatively to confirm her consent for surgery on the left hip but does not mark the surgical site. The surgeon is called away and returns to find the patient anesthetized and in the operating room. As the team initiates their routine sign-in, there is a power outage; they pause until the generator turns on. As the sign-in resumes, they pause again for a nurse to ask the surgeon about another patient. Several team members then position and drape the patient for surgery on the right hip. They conduct a “time out” just before the first incision, and the surgery proceeds.
The patient initiates a legal action against the surgeon for wrong-side surgery. The hospital and the CMPA pay a shared settlement to the patient.
Considerations
There were triggers for untoward events in this scenario. If the perioperative nurses, ACT (Anesthesia Care Team) and surgical team, had paid attention, it could have saved this patient from harm. Even if ONE person had paid attention and spoken up, it would have made all the difference.
“The surgical safety checklist can be an effective tool for fostering team communication and preventing wrong-side surgery if used correctly. It is crucial that surgical team members reach a shared understanding of the correct side in the ‘briefing’ phase (before anesthesia) and in the ‘time out’ phase (before skin incision), with their full attention in each phase” (CMPA, 2021).