{"id":522,"date":"2022-11-29T08:09:41","date_gmt":"2022-11-29T08:09:41","guid":{"rendered":"https:\/\/perioperative1000.slc-courses.ca\/?p=522"},"modified":"2022-12-15T17:30:40","modified_gmt":"2022-12-15T17:30:40","slug":"module-4-c-from-blame-to-system-failures-good","status":"publish","type":"post","link":"https:\/\/perioperative1000.slc-courses.ca\/?p=522","title":{"rendered":"Module 4: C. From Blame to System Failures"},"content":{"rendered":"\n<h2>From Blame to System Failures<\/h2>\n\n\n\n<p>The evolution of terms: medical error to adverse events to patient safety <a id=\"post-443-_Int_ysykEqsu\"><\/a>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.<\/p>\n\n\n\n<p>Adverse events are not typically attributed to poorly skilled OR team members but <a id=\"post-443-_Int_TPxzJ9JT\"><\/a>to the failure of patient care delivery processes (Clendinneng, 2020).<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<div class=\"wp-container-3 wp-block-columns\">\n<div class=\"wp-container-1 wp-block-column\">\n<h5>Teamwork and Safety<\/h5>\n\n\n\n<ul><li>Teamwork is a subtle factor contributing to safety<\/li><li>Non-technical skills needed by OR Nurses<\/li><li>Scrub Practitioners\u2019 List of Intraoperative Non-Technical Skills (SPLINTS)<\/li><li>NTS can be taught and learned through role modelling, practice, and constructive feedback (Flin et al., 2014)<\/li><\/ul>\n\n\n\n<p>AORN (2017).<a rel=\"noreferrer noopener\" href=\"https:\/\/www.prweb.com\/releases\/2017\/06\/prweb14400798.htm\" target=\"_blank\">AORN and The Joint Commission Team Up For Time Out Super Heroes<\/a><\/p>\n<\/div>\n\n\n\n<div class=\"wp-container-2 wp-block-column\">\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" width=\"1024\" height=\"683\" src=\"https:\/\/perioperative1000.slc-courses.ca\/wp-content\/uploads\/2022\/11\/equipo-medico-realizando-operacion-quirurgica-1024x683.jpg\" alt=\"\" class=\"wp-image-539\" srcset=\"https:\/\/perioperative1000.slc-courses.ca\/wp-content\/uploads\/2022\/11\/equipo-medico-realizando-operacion-quirurgica-1024x683.jpg 1024w, https:\/\/perioperative1000.slc-courses.ca\/wp-content\/uploads\/2022\/11\/equipo-medico-realizando-operacion-quirurgica-300x200.jpg 300w, https:\/\/perioperative1000.slc-courses.ca\/wp-content\/uploads\/2022\/11\/equipo-medico-realizando-operacion-quirurgica-768x512.jpg 768w, https:\/\/perioperative1000.slc-courses.ca\/wp-content\/uploads\/2022\/11\/equipo-medico-realizando-operacion-quirurgica-1200x800.jpg 1200w, https:\/\/perioperative1000.slc-courses.ca\/wp-content\/uploads\/2022\/11\/equipo-medico-realizando-operacion-quirurgica.jpg 1380w\" sizes=\"(max-width: 1024px) 100vw, 1024px\" \/><\/figure>\n<\/div>\n<\/div>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h5>Example of SPLINTS<\/h5>\n\n\n\n<p><strong>Non-Technical Skill: Situational Awareness<\/strong><\/p>\n\n\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-9\" class=\"h5p-iframe\" data-content-id=\"9\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"Module 4: Example of SPLINTS - Situational Awareness\"><\/iframe><\/div>\n\n\n\n<div style=\"height:30px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p><strong>Non-Technical Skill: Communication and Teamwork<\/strong><\/p>\n\n\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-10\" class=\"h5p-iframe\" data-content-id=\"10\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"Module 4: Example of SPLINTS - Communication and Teamwork\"><\/iframe><\/div>\n\n\n\n<div style=\"height:30px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p><strong>Non-Technical Skill: Task Management<\/strong><\/p>\n\n\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-11\" class=\"h5p-iframe\" data-content-id=\"11\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"Module 4: Example of SPLINTS - Task Management\"><\/iframe><\/div>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h5>\ud83e\udde0 Graded Activity<\/h5>\n\n\n\n<p>In Blackboard, complete the<strong> Graded Activity: Reflection<\/strong><\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<div class=\"wp-container-6 wp-block-columns\">\n<div class=\"wp-container-4 wp-block-column\">\n<h5>Focusing on Safety<\/h5>\n\n\n\n<ol><li>A positive way to look at safety is to determine what goes according to plan.<\/li><li>A proactive approach to understanding what goes right helps enforce safety.<\/li><li>ORs with systems processes in place, team members who communicate, <a id=\"post-443-_Int_TgPcN8LQ\"><\/a>collaborate, and share goals of safe outcomes, have <a id=\"post-443-_Int_f0sYMp1d\"><\/a>fewer adverse events.<\/li><li>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\u2019 mistakes. Debrief with a senior nurse in the room to understand what went wrong and how to avoid future mistakes.<\/li><\/ol>\n<\/div>\n\n\n\n<div class=\"wp-container-5 wp-block-column\">\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" width=\"1024\" height=\"682\" src=\"https:\/\/perioperative1000.slc-courses.ca\/wp-content\/uploads\/2022\/11\/equipo-medico-que-realiza-operacion-quirurgica-hospital-1024x682.jpg\" alt=\"\" class=\"wp-image-541\" srcset=\"https:\/\/perioperative1000.slc-courses.ca\/wp-content\/uploads\/2022\/11\/equipo-medico-que-realiza-operacion-quirurgica-hospital-1024x682.jpg 1024w, https:\/\/perioperative1000.slc-courses.ca\/wp-content\/uploads\/2022\/11\/equipo-medico-que-realiza-operacion-quirurgica-hospital-300x200.jpg 300w, https:\/\/perioperative1000.slc-courses.ca\/wp-content\/uploads\/2022\/11\/equipo-medico-que-realiza-operacion-quirurgica-hospital-768x512.jpg 768w, https:\/\/perioperative1000.slc-courses.ca\/wp-content\/uploads\/2022\/11\/equipo-medico-que-realiza-operacion-quirurgica-hospital-1536x1024.jpg 1536w, https:\/\/perioperative1000.slc-courses.ca\/wp-content\/uploads\/2022\/11\/equipo-medico-que-realiza-operacion-quirurgica-hospital-1200x800.jpg 1200w, https:\/\/perioperative1000.slc-courses.ca\/wp-content\/uploads\/2022\/11\/equipo-medico-que-realiza-operacion-quirurgica-hospital-1980x1320.jpg 1980w, https:\/\/perioperative1000.slc-courses.ca\/wp-content\/uploads\/2022\/11\/equipo-medico-que-realiza-operacion-quirurgica-hospital.jpg 2000w\" sizes=\"(max-width: 1024px) 100vw, 1024px\" \/><\/figure>\n<\/div>\n<\/div>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h5>Case Study<\/h5>\n\n\n\n<p>CMPA (2021). Proactive steps to ensure safe joint surgery<\/p>\n\n\n\n<div class=\"wp-container-9 wp-block-columns\">\n<div class=\"wp-container-7 wp-block-column\">\n<blockquote class=\"wp-block-quote\"><p><strong>Case Excerpted from Canadian Medical Protection Agency (2021). <\/strong><\/p><p>In Canada from 2018-2019, over 137,000 hip and knee <a id=\"post-443-_Int_iEUu1plH\"><\/a>arthroplasty surgeries were performed. Even routine elective joint surgeries <a id=\"post-443-_Int_dUfGRRkR\"><\/a>harbor patient risks, as seen in the 198 medico-legal cases during that <a id=\"post-443-_Int_3a3VnqDk\"><\/a>time when most were elective surgeries<a id=\"post-443-_Int_2l4SjyUt\"><\/a>.<\/p><\/blockquote>\n<\/div>\n\n\n\n<div class=\"wp-container-8 wp-block-column\">\n<blockquote class=\"wp-block-quote\"><p><strong>Wrong-side surgery and team communication <\/strong><\/p><p>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.<\/p><\/blockquote>\n<\/div>\n<\/div>\n\n\n\n<div style=\"height:30px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p><strong>Case scenario: A patient undergoes surgery on the wrong hip <\/strong><\/p>\n\n\n\n<p>A woman provides informed consent to undergo hemiarthroplasty of the&nbsp;left&nbsp;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&nbsp;right&nbsp;hip. They conduct a \u201ctime out\u201d just before the first incision, and the surgery proceeds.<\/p>\n\n\n\n<p>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.<\/p>\n\n\n\n<div style=\"height:30px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p><strong>Considerations <\/strong><\/p>\n\n\n\n<p>There were <a id=\"post-443-_Int_WMS6ll3o\"><\/a>triggers for untoward <a id=\"post-443-_Int_xgS87x7w\"><\/a>events in this scenario. If the perioperative nurses, <a id=\"post-443-_Int_hmdZHPwu\"><\/a>ACT (Anesthesia Care Team) and surgical <a id=\"post-443-_Int_VUyTqC8U\"><\/a>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<a id=\"post-443-_Int_fyyo1K6c\"><\/a>.<\/p>\n\n\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-21\" class=\"h5p-iframe\" data-content-id=\"21\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"Module 4: Case Study Considerations\"><\/iframe><\/div>\n\n\n\n<div style=\"height:30px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p><em>\u201cThe 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 \u2018briefing\u2019 phase (before anesthesia) and in the \u2018time out\u2019 phase (before skin incision), with their full attention in each phase\u201d (CMPA, 2021).<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>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 [&hellip;]<\/p>\n","protected":false},"author":5,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"templates\/template-content.php","format":"standard","meta":[],"categories":[16],"tags":[],"wf_post_folders":[6],"_links":{"self":[{"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/posts\/522"}],"collection":[{"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/users\/5"}],"replies":[{"embeddable":true,"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=522"}],"version-history":[{"count":31,"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/posts\/522\/revisions"}],"predecessor-version":[{"id":1362,"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/posts\/522\/revisions\/1362"}],"wp:attachment":[{"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=522"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=522"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=522"},{"taxonomy":"wf_post_folders","embeddable":true,"href":"https:\/\/perioperative1000.slc-courses.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fwf_post_folders&post=522"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}