SSSL + Medical Error + Patient Safety Policy + URSI 🚓 Flashcards
(28 cards)
Origin of Safe Surgery Safe Life (SSSL)
- Formulated by WHO in 2004 and introduced in 2008 ( Washington DC)
- launched in Malaysia in Nov 2009 ( Langkawi)
What are the 10 objectives of safe surgery?
1) correct site and surgery
2) Prevent anaesthesia complication and pain
3) Prevent lung related complication
4) Anticipate bleeding
5) Prevent drug allergy and adverse event
6) Prevent SSI
7) Avoid retained instrument or swab
8) Correct labelling of specimen
9) Good communication between surgeon, anaesthetist and staffs
10) Hospitals and public health system will establish routine surveillance of surgical capacity, volume and results
Strategies/ Aim of SSSL
goal: to have zero wrong side surgery and zero unintended retained foreign body
What are the component of SSSL?
1) Pre transfer checklist
2) operating team checklist
3) Swab & instrument count form
4) Post operative transfer check list
Component 1 ( pre transfer check list)
- Filled up by ward nurse before sending patient to OT and at the OT transfer area
- Nurse in OT will check the consents, details of patient and etc
1) PRE TRANSFER PRE-OPERATIVE CHECK LIST:
Contained:
- Patient’s profile
- Patient’s name and tag
- Operation site, marked
- Last meal
- Accessories: denture, jewellary
- Premedication: drug given
- Blood availability
- Case note, old note, XRay available
- Chart BP/PR
- Person handed over by and received by
Component 2 ( operating team checklist)
- Filled by circulating nurse once patient entered the OT
- Components include:1) Sign in : before induction ( by anaes and nurse)
2) time out: Whiteboard ( patient, diagnosis, procedure, members of operating team), performed before skin incision
3) Check in : Before starting incision
4) Intraoperative communication :
- periodic updates ( progress of surgery - if exceeding time )
- shout out ( pack in and out, instrument fell down, equipment malfunction)
- Pre closure disclosure: inform before closing the abdomen and nurses will commence last final swab count, this will enable the anaesthetist to plan for reversal
5) Sign out:
Post-operative phase:
Before leaving OR, following are done:
- Nurses have reviewed the following aloud with team:
Name of correct procedure performed as recorded
Instrument, needle, sponge, gauze - correctly counted and Specimen is correctly labeled including patient’s name Any issues with equipment that need to be addressed
- Surgeon/anaesthesia review aloud key concerns for recovery and care of the patient
Post-operative phase - Inform relatives:
- Inform relatives after procedure is encouraged.
- Inform the progression if operation >3H
- operative specimens are also shown to the relatives.
- This usually enhances communication.
Component 3 ( swab and instrument count checklist)
- make sure swab and instrument count correct
- also can report regarding malfunction or missing instruments documented
- Correct count on instrument/gauze/blade/needle
- Documented specimen sent
- Documented incident/equipment failure
- Signature by incharge nurse and surgeon
Components 4 ( Pre-discharge checklist)
4) PREDISCHARGE CHECK LIST
- Patient’s identification and tag
- Consciousness level
- Vital signs, pain score
- Operative site, dressing
- Drain, tube, catheter checking
- IV access, infusion
- Blood product used and unused
- Case note, old note, Xrays, operative notes, GA form - available
- Post op pain relief order
- Any special requests/order etc.
SSSL principle
Anaes part: (A, B, C)
1) Airway ( anticipate a difficult or failed airway.)
- Readily available suction, malleable stylet, Magill introducing forceps, flexible bronchoscope, cricothyroidotomy cannula.)
2) Allergies
3) Breathing ( anaesthesia, analgesia)
4) Blood loss ( anticipate blood loss - GXM ready?)
5) Effective communication among team members
Surgeon part:
1) verification of patient ( make sure correct patient, correct sites)
2) Prevention against retention of instruments and sponges in surgical wounds
3) Surgical specimens
- Correct patient, specimen name and location (site and side)
4)Routine surveillance of surgical capacity, volume and results
- M&M rate, POMR, SSI rate, surgical Apgar Score (blood loss, PR, BP)
5) Prevention against SSI
Malaysian Patient Safety Goals 2.0, 2021
- Infection prevention and control
- Safe surgery saves lives
- Medication safety
- Transfusion safety
- Fall prevention
- Patient identification
- Incident report and learning system
Role of surgeon in making surgery is safer?
- Offering the right surgical procedure
- Performed by right surgeon (in-charge surgeon what he/she can do or cant do, well trained and get credentialing)
- Operating surgeon should do pre and post operation visit (to prevent wrong patient/wrong surgery/wrong site/wrong indication, improve rapport, reduce chance of ligitilation)
- Team work and preparation (discuss operative strategies)
- Behave (be early/on time, unhurried preparation especially positioning, team and patient comfortable if surgeon is around)
- Performed time out
- Should aware on risk identification and management:
RED FLAG SITUATION:
V Patient with similar name in the same OT
Blood requirement and availability
V Incharge surgeon - not available
TAKE ACTION ON ISSUE ARISES.
What are the types of Medical Error?
- Adverse event - injury caused by medical management
- Negligence - care to pt that falls below the standard of care
- Near miss - error that is potential to cause adverse event but fails by chance
- Sentinel event - unexpected occurrence involving death or serious physical/ psychological injury not related to natural course of disease.
What are the implications of retained surgical items in patient ?
Patient:
- If this is true, then surgeon and team is responsible for the medical error
- Pt may require relaparotomy after confirmation with imaging that there is unintended retained surgical instrument.
Relaparotomy may lead to increase in morbidity and post op complication especially in high-risk group of pts.
Department:
Dept should inform the pt and caregiver regarding the error.
May exposed dept to litigation and its consequences.
- May damage the reputation of organization with loss of trust.
What is the next course of action in retained surgical item case?
- Verify the facts of the case → from pt, operating notes especially the SSSL checklist, reports, and personnel
- Inform the hospital director and initiate investigation → need to ascertain facts and to decide next course of action.
- Provide early legal advice for individual and organization
- Conduct an internal investigation, and it is to be headed by the senior if not the most senior person in the dept.
- Ensure all documents related to the case secured and kept confidential
Once error established, high level official meeting with patient and caregiver should be conducted. - This issue should be handled with tactfulness and diplomacy.
How to minimize such error from happening?
- Audit of adherence to SSSL checklist
- Train, credential, privilege new surgeon and medical officer doing operation
- Build a culture of speaking up whenever something is not right especially when the count is not adequate. Do not wait till the end of operation.
- Regular mortality and morbidity meeting to learn from various error.
What is Sentinel Event and how to manage?
SENTINEL EVENT
Sentinel Event is defined by The Joint Commission(TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness.
- Sentinel events include all of the following, even if the outcome was not death or major permanent loss of function:
* Infant abduction, or discharge to the wrong family.
* Unexpected death of a full-term infant.
* Severe neonatal jaundice (bilirubin over 30 milligrams/deciliter).
* Surgery on the wrong individual or wrong body part.
* Instrument or object left in a patient after surgery or another procedure.
* Rape in a continuous care setting.
* Suicide in a continuous care setting, or within 72 hours of discharge.
* Hemolytic transfusion reaction due to blood group incompatibilities. [2]
* Radiation therapy to the wrong body region or 25% above the planned dose.
What to do?
* Inform consultant
* Make an incident report
* Go with consultant to explain to patient
* Remedial action (salvage situation)
* Meeting and audit to prevent further medical error
What is Adverse Event?
ADVERSE EVENT
- Defined as any unfavourable and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal (investigational) product, whether or not related to the medicinal (investigational) product.
- Grade 1 Mild AE
- Grade 2 Moderate AE
- Grade 3 Severe AE
- Grade 4 Life-threatening or disabling AE
- Grade 5 Death related to AE
Patient Safety Policy
Quality of Surgical Services
Consents
What is Universal Precaution
Double gloving with an indicator system provides the best protection and allows the timeliest identification of perforations. ( glove will turn colour)
Overview of Root Cause Analysis (RCA)
Root Cause Analysis (RCA) is a structured investigation that aims to identify the “root cause” of the problem and actions necessary to eliminate it. It is a risk management tool to understand WHY the problem occurs.
Concept of RCA2 was introduced by National Patient Safety Foundation, USA in 2015.
STEP 6 (determine the root cause) with the 5’s WHY approach : uses fish bone diagram or ishikawa diagram
This is an example of “5 Whys” approach in a case of Medication
Error :
o Why did the nurse give wrong medication to the wrong
patient? Because she thought he was the right patient.
o Why did she think he was the right patient? She did not use
“two identifiers” identity the correct patient.
o Why didn’t she use two identifier to identify correct patient?
She did not know this policy.
o Why was she not trained in this policy ? Because she is a senior
staff and has beeen working for 10 years
o Why senior staff were not included in the training? We assume
senior staff know what to do
Incident Reporting
Examples of incidents that need to be reported:
7. BRIEF DESCRIPTION OF WHAT HAPPENED (Please fill in the blanks)
The description should explain what happen prior and during the incident and how it occurred. Do include any additional
information which you think may lead to the incident.
i. Wrong surgery/procedure –wrong site, side or patient
ii. Unintended retained foreign body in patient after an operation/procedure
iii. Error in transfusion of blood/blood products
vi. Medication error (please fill in MERS form as well)
v. Patient fall in the facility
vi. Obstetric related incidents
vii. Adverse outcome of clinical procedure
viii. Pre-hospital care and ambulance service related incident
ix. Radiotherapy related incident
x. Patient suicide / attempted suicide
xi. Patient discharged to wrong family members / next-of -kin
xii. Assault/ battery of patient
xiii. Unanticipated Fire – Fire, flame, or unanticipated smoke, heat, or flashes occurring in the facility
xiv. Others type of incident
Clinical Governance
