Documentation, relating to surgical error.

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  • (Safe Surgery Saves Lives,2008)
  • (Safe Surgery Saves Lives,2008)
  • (Safe Surgery Saves Lives,2008)
  • (Mulloy, & Hughes, 2008)
  • (Mulloy, & Hughes, 2008)
  • From Joint Commission on Accreditation of Healthcare Organizations based on WHOguideleies(Mulloy, & Hughes, 2008)
  • From Joint Commission on Accreditation of Healthcare Organizations(Mulloy, & Hughes, 2008)
  • From Joint Commission on Accreditation of Healthcare Organizations(Mulloy, & Hughes, 2008)
  • Before induction of anaesthia, before skin incision, before patient leaves operating roomAll require nurse to be present(Surgical Safety Checklist,2009)
  • From Western Australia Health DepartmentStep 1: ensure that valid informed consent has been obtainedCompliance with the Consent to Treatment Policy for the Western Australian Health System is mandatory. as a matter of policy, no surgical operation, medical, anaesthetic, radiology or oncology procedures may be performed without the consent of the patient, if the patient is a competent.Step 2: Confirm the patient’s identityPolicy recognises that the patient is an integral member of the team undertaking the verification process. When the patient is being prepared for their treatment/procedure, it is recommended that a ‘team time-out’ is taken, and that the patient is involved in the initial stages of the five-step verification process. Prior to the patient receiving any medication that could affect his/her cognitive function, a member of the clinical team will take ‘time-out’ to confirm the following details with the patient: the patient’s full name and date of birth; (the patient should be asked to state not confirm these details);the type of treatment/procedure being performed; the reason for the treatment/procedure; and the side and site of the treatment/procedure. Staff must check the patient’s responses against the patient’s identification band, consent form and other information provided in the patient’s medical record. The completion of this Step must be recorded on a checklist, which should be completed at the end of each stage of the five-step verification process and stored in Theatre management System or in the patient’s medicalStep 3: mark the site of the surgery or invasive procedure. The site of the surgery or invasive procedure should ideally be marked by the person performing the surgical or interventional procedure.. The intended site of incision or site of insertion must be unambiguously markedStep 4: Take a final ‘team time-out’ in the operating theatre, treatment or examination area., all members of the clinical team (e.g. proceduralist, anaesthetist, nurse) should participate in a final ‘team time-out’.The final ‘team time-out’ should be consistently initiated by a designated member of the clinical team. The success of the ‘team time-out’ process is totally reliant on active communication amongst all members of the clinical teamStep 5: ensure the correct and appropriate documents and diagnostic images are availableClinical errors caused by poor quality documentation or improperly labelled diagnostic images are a real vulnerability in the process. Clinicians and hospitals/health services alike have a responsibility to develop and implement policies and procedures to mitigate against this vulnerability. (Correct Patient, Correct Procedure and Correct Site Policy and Guidelines for Western Australian Health Services,2006)
  • Algorithm for assuring correct invasive procedures in all clinical settings(Correct Patient, Correct Procedure and Correct Site Policy and Guidelines for Western Australian Health Services,2006)
  • Pre-operative/pre-treatment verification checklistDocumented and signed on this official document which is kept in the patient file.(Correct Patient, Correct Procedure and Correct Site Policy and Guidelines for Western Australian Health Services,2006)
  • Documentation, relating to surgical error.

    1. 1. DOCUMENTATION, RELATING TOSURGICAL ERRORJess Morritt
    2. 2. SURGERY An estimated 234 million major operations are performed around the world each year, which equals one operation for every 25 people alive. Each year an estimated 63 million people undergo surgical treatment due to traumatic injuries, another 10 million operations are performed for pregnancy- related complications, and 31 million more are undertaken to treat malignancies.
    3. 3. RAISING THE STANDARD TO MAKE SURGICALCARE SAFER WORLDWIDE Surgical care has been an essential component of health systems worldwide for more than a century. Although there have been major improvements over the last few decades, the quality and safety of surgical care has been dismayingly variable in every part of the world. The Safe Surgery Saves Lives initiative aims to change this by raising the standards that patients anywhere can expect.’
    4. 4. 5 FACTS ABOUT SURGICAL SAFETY 1. Complications after inpatient operations occur in up to 25% of patients. 2. The reported crude mortality rate after major surgery is 0.5–5%. 3. In industrialized countries nearly half of all adverse events in hospitalized patients are related to surgical care. 4. At least half of the cases in which surgery led to harm are considered to be preventable. 5. Known principles of surgical safety are inconsistently applied even in the most sophisticated settings.
    5. 5. WRONG-SITE SURGERY (WSS)What is it? Top Causes Wrong site  70% communication Wrong patient failure Wrong procedure  64% procedural non compliance  46% leadership issues
    6. 6. WSS RISK FACTORS  Emergency cases  Multiple surgeons  Multiple procedures  Deformities  Obesity  Time pressures  Unusual equipment or set up  Room changes
    7. 7. UNIVERSAL PROTOCOL - PREOPERATIVEVERIFICATION PROCESSPurpose Process To ensure that all of the relevant  An ongoing process of documents and studies are available prior to the start of the information gathering and procedure and that they have verification been reviewed and are consistent with each other and  Begins with the with the patients expectations determination to do the and with the teams procedure, continuing understanding of the intended patient, procedure, site, and, as through all settings and applicable, any implants. interventions involved in the Missing information or preoperative preparation of discrepancies must be the patient, up to and addressed before starting the including the "time out" just procedure. before the start of the procedure.
    8. 8. UNIVERSAL PROTOCOL - MARKING THEOPERATIVE SITEPurpose Process To identify  For procedures involving right/left unambiguously the distinction, multiple intended site of incision structures (such as or insertion. fingers and toes), or multiple levels (as in spinal procedures), the intended site must be marked such that the mark will be visible after the patient has been prepped and draped.
    9. 9. UNIVERSAL PROTOCOL - "TIME OUT" IMMEDIATELYBEFORE STARTING THE PROCEDUREPurpose Process To conduct a final  Active communication verification of the among all members of correct the surgical/procedure patient, procedure, site team, consistently initiated by a designated and, as member of the team, applicable, implants. conducted in a "fail-safe" mode, i.e., the procedure is not started until any questions or concerns are resolved.
    10. 10. FIVE STAGES OF THE ‘CORRECT PATIENT, CORRECTSITE AND CORRECT PROCEDURE’ POLICY Step 1: ensure that valid informed consent has been obtained Step 2: Confirm the patient’s identity Step 3: mark the site of the surgery or invasive procedure Step 4: Take a final ‘team time-out’ in the operating theatre, treatment or examination area. Step 5: ensure the correct and appropriate documents and diagnostic images are available
    11. 11. REFERENCES Correct Patient, Correct Procedure and Correct Site Policy and Guidelines for Western Australian Health Services. (2006). Retrieved January, 2, 2012, from http://www.safetyandquality.health.wa.gov.au/docs/correct_ps p/Correct_Patient_Policy_and_Guidelines_Final.pdf Mulloy, D., & Hughes, R. (2008). Wrong-Site Surgery: A Preventable Medical Error. Retrieved January 2, 2012, from http://www.ncbi.nlm.nih.gov/books/NBK2678/ Safe Surgery Saves Lives. (2008). Retrieved January 2, 2012, from http://www.who.int/patientsafety/safesurgery/knowledge_base/ SSSL_Brochure_finalJun08.pdf Surgical Safety Checklist. (2009). Retrieved January 2, 2012, from http://whqlibdoc.who.int/publications/2009/9789241598590_e ng_Checklist.pdf

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