OR safety Flashcards
What are some hot topics for a culture of safety?
- Clear communication/ team building
- Clinical events checklists for entire team (AI)
- Timeouts
- Retained guide wires
- Wrong site surgery
- Central line infections
- Medication errors
- Workspace contamination
What are some general safety issues?
- Patient
- Anesthesia providers
- Surgical team
- Perioperative workers
- Pregnancy
What are some exposures in the OR? (11)
- Anesthetic Gases
- Infections
- Chemical
- Radiation
- Magnetic fields
- Lasers
- Electricity
- Fire
- Noise
- Light
- Personal hazards
What are some considerations with exposure to Nitrous oxide?
- Only anesthetic gas shown to be teratogenic
- Nitrous oxide- inactivates vitamin B12 dependent enzyme methionine synthetase involved in DNA production, myelin sheath assembly, and methyl substitution in neurotransmitters
- Leads to anemia, polyneuropathy
- Increase infertility (difficulty with conception)
- Increase rate of spontaneous abortions
What are some consideration with exposure with Halogenated agents?
- Studies inconclusive
- Reproductive
- Infertility (difficulty with conception)
- Spontaneous abortion higher incidence
- Premature labor and/or delivery
- Bone marrow depression
- Numbness, tingling, and muscle weakness
- Liver disease
What is the standard by the National Institute for Occupational Safety and Health (NIOSH), Occupational Safety and Health Administration (OSHA)?
- Nitrous oxide less than 25 ppm
- halogenated agents less than 2 ppm OR 0.5 ppm when combined with nitrous
How are anesthetic gases managed? (equipment, practice, ect)
- scavenge
- routine machine maintenance
- airway management
- vaporizer (filling)
- adequate air exchange in OR
Whats included in needle safety?
- One Needle, One Syringe, and Only One Time
- Don’t recap
- Needle-less systems
- Dispose of properly
What are some considerations with HIV infections?
•Greatest risk is needlestick injuries, deep cutaneous injury with a large hollow needle
- Can also occur with a small break in skin or splatter in mouth
•0.3%-0.4% seroconversion rate after single exposure needlestick
- occurs within 6-12 weeks
- retested 6-12 weeks and at 6 mos after exposure
- postexposure antiretroviral prophylaxis regimens
- started <24hours after exposure
What are some consideration with Hep B and Hep C infections?
Hepatitis B
•Hepatitis B is the most serious occupational health danger facing anesthesia providers
- 20-49% providers have markers of previous exposure to Hep B
- Risk of infection after HBV-contaminated percutaneous exposure is 37-62%
- Vaccination
- Virus remains active 1 week in dried blood
Hepatitis C
•Predominantly from transfusion
What are some other infections to consider? (3)
- Herpes
- Rhinovirus
- Tuberculosis
- Spread by airborne droplets
- 10% chance of developing after exposure
- DC has the highest incidence
- Isolation, filters, protective equipment, fit-tested NIOSH-approved N95 or higher level respirator, annual skin tests
- Treatment: Isoniazide, rifampicin
What are the policies/regulation regarding the CDC- Universal precaution, OSHA Guidelines, and 2002 Needlestick Safety and Prevention Act?
CDC - Universal precautions
- gloves
- eyewear
- gowns
- masks
- handwashing
- needles
- isolation
OSHA – Guidelines to minimize occupational exposure to blood-borne pathogens (employer’s responsibilities)
2002 Needlestick Safety and Prevention Act
- Do not recap
- Needleless systems
- Other exposure control plans (ie. puncture resistant containers)
Who are at risk for Latex exposure?
What are the symptoms?
What are the allergy association?
How do you manage exposure to Latex?
•People at risk:
- Patients with frequent exposure (spina bifida, urologic patients)
- Health care workers with frequent exposure
- Symptoms- dermatitis, urticaria, rhinitis, conjunctivitis, asthma, laryngeal edema, anaphylactic shock
- Associated with allergy to avocado, potato, banana, tomato, chestnuts, kiwi, papaya
- Management- reduce undue exposure, hand washing after exposure, consider pretreatment
- Latex free equipment
What are the risk, recommendations, and management for Methylmethacrylate?
- Acrylic cement used for prostheses
- Supplied as liquid and power components that are mixed and produce toxic vapors
- Risks-
- Patient- hypotension, bradycardia, cardiac arrest
- ***effects can last up to 5 days
- Health care providers- dyspnea, wheezing, coughing, rhinorrhea, hypertension, erythema, headache
- Caution with pregnancy
•Recommendations (NIOSH)
- Maximum 8-hour exposure to 100 ppm
•Management
- Patient – hydration, vasoactive support
- Health care providers- adequate ventilation, scavenge
•
What are some Chemical and Biological Weapons and treatments? (7)
Nerve Agents (Sarin gas)
- Irreversible inhibition of acetyl & butyryl-cholinesterase
- Hypersecretions, bradycardia, AV block, bronchospasm, seizures, resp. depression, paralysis
- Treatment: Atropine and OXIMES
Vesicant agents (“mustard gas”)
- “blistering agents”
- Treatment: respiratory support, fluid therapy
Choking agents (chlorine/ phosgene)
- Laryngospasm, pulmonary edema
- Treatment: respiratory support, limit inflammation
Blood agents (cyanide)
- Inhibits cytochrome oxidase enzymes
- Hypoxia
- Treatment: Sodium thiosulfate
Toxins (botulinum toxin)
- Inhibits release of acetylcholine
- Treatment: antiserums
Biologicals (anthrax)
- Pulmonary edema, widened mediastinum
- Antibiotics, vaccine
Ricin
- Inhaled, injected, or ingested
- Respiratory distress, chest tightness, pulm edema
What are the risks, policies/regulations, and management with Ionizing radiation?
- Risks - rapidly replication cells
- Greatest risk for us from fluoroscopy
- Policies/regulations
- Max. yearly exposure < 5 rem (during pregancy <500 mrem)
•Management
- Distance- minimum of 3 feet (6 ft air = 9 inches concrete = 2.5 mm lead)
- Protection (aprons, lead shields, walls)
- Exposure: eyes, reproductive organs, thyroid
What are are the considerations and risks with Magnetic Fields (MRI)?
- MR imaging does not require ionizing radiation, but high radiofrequency power
- Risk- magnetic fields may be changed to electric fields (by connection of two circuit elements by a wire or resistor)
- Dangerous with pacemakers or implanted stimulators, vascular clips, or any other ferromagnetic metal
- Noise
- Small space
- NO METAL ALLOWED!!!!!
- Unknown effects on pregnancy
What does LASERS stand for?
What do they emit?
What are the risk and protection needed for using Lasers?
•Light Amplification by Stimulated Emission of Radiation
- CO2
- Nd:YAG
- argon
•Eye injury – cornea, retinal burns, destruction of macula, caracts
- protective eye wear
•Vapors and debris – infections (HVP- human papilloma virus, HIV)
- plume evacuator system, high filtration masks
What’s part of a fire triad?
What are some precautions to take to prevent fires?
•Fire triad
- Oxygen/nitrous, fuel, ignition source
- Use lowest concentration of oxygen possible, avoid nitrous oxide, avoid paper drapes, beware of oil-based lubricants and alcohol based preps, use special ETT and fluid in cuff
- Beware of tenting, too much sedation
- Know location of nearest fire extinguisher, oxygen shut-off valves
- Fire drills:
- ERASE: extinguish, rescue, activate, shut (doors), and evaluate
What do you do if theres an OR fire?
What do you do if theres an airway fire?
If fire:
- remove drapes and burning material
- douse flames with normal saline
- assess for smoke inhalation
If airway fire:
- remove ETT
- turn off all gases
- extinguish fire/ pour saline into airway
- remove burning materials
- mask ventilate, assess injury, replace ETT, bronchoscopy
OR Fire Algorithm
What are the considerations and risk with Electricity?
•From: equipment (surgical, anesthesia), monitors, bed
- *defibrillation, electroconvulsive therapy
•Risk of Shock – electric shock occurs when current flows through the body due to contact with 2 conductors @ different voltages
- even small amounts of electrical current can disrupt muscle and nerve function (macroshock, microshock)
- Other risks- burns, explosions, arrhythmias, pacemaker disruption, FIRE!
Whats Macroshock?
- Large voltage of electricity flowing through a person from skin contact
- Response depends on amplitude and frequency of current.
- 1 mA = perception threshold
- 5 mA = maximal harmless current intensity
- 10-20 mA = “let-go” threshold, then sustained muscle contraction
- 50 mA = pain & mechanical injury
- 100-300 mA = ventricular fibrillation
- >6000 = sustained myocardial contraction, temporary respiratory paralysis, burns
Whats Microshock?
•Direct application of very small amounts of electric current in a patient who has an external conduit that is in direct contact with heart
- cardiac pacing wires
- invasive monitoring catheters
- Equipment maximum leakage allowed = 10 uA
- A current as low as 50-100 uA can be fatal (ventricular fibrillation)
- An intact equipment ground wire is the most important factor in preventing microshock; LIM cannot protect against microshock
Explain grounding of electrical current and isolated/ungrounded electrical current.
Grounded electrical current
- One of the 2 wires is connected to earth ground
- provides low-resistance pathway for currents to ground
- dissipates leakage current
Isolated or ungrounded electrical current
- the current is isolated from ground potential
- Requires use LIM
Explain Line Isolation Monitor
- Device that continuously monitors the integrity of an isolated power system and helps reduce the risk of shock in the OR
- LIM alarms at 2-5 mA or an impedance of <60,000 ohms
- Device will change system to a conventional grounded system if a faulty piece of equipment is connected to the isolated power system
- If alarms, check gauge:
- If between 2-5 – too many pieces of electrical equipment plugged in
- If >5 – faulty piece of equipment, unplug
What is Electrocautery?
Explain Unipolar vs. Bipolar.
•Cutting or coagulation combining high resistance with high current
Unipolar- most common
- Current applied via cutting/coagulation electrode (generates heat in a very small area).
- Second electrode = ground pad outside surgical field.
- Proper application of return plate very important
- Appropriate amount of gel
- Intact return wire
- Place close to operative site
- Caution with flammable preps
- If pacemaker, place below thorax and prepare for treating dysrhythmias, including magnet, defibrillator, external pacemaker
- Can have reprogramming and microshock
Bipolar
- Two pencil-point electrodes applied to site and current flows between them.
- Generates less power than unipolar
- Recommended for patients with pacemakers.
- But, pacemaker still at risk of program disruption
What are some consideration with Noises?
- MRI, ESWL, drills, monitors, surgical equipment, alarms, music
- Hazardous noise when >90 decibels (dB) for 8 hours/day
- Interferes with work performance, vigilance, fatigue, irritability, hormonal stress response
What are some consideration with lighting?
- Surgical lights
- Laparoscopic equipment
- Dark
What are some personal hazard of our profession?
- Physical - injury, temperature, sleep deprivation/fatigue, illness, aging
- Psychological- substance abuse, stress, interpersonal, economic, distractions
- Policies/regulations- AANA, COA, departmental
What are the types of Medication errors?
Types of Errors:
- Omission — drug not given
- Repetition — extra dose of an intended drug
- Substitution — incorrect drug instead of the desired drug; a swap
- Insertion — a drug that was not intended to be given at a particular time or at any time
- Incorrect dose — wrong dose of an intended drug
- Incorrect route — wrong route of an intended drug
- Other — usually a more complex event not fitting the categories above
When and if an error occurs?
- Reporting
- Systems approach to analysis
- CQI/QA
- Disclosure- What do we tell the patient??
- Legal Ramifications
What is part of provider wellness?
- Professional self-care is influenced by the ability of practitioners to manage their lifestyles and happiness through personal choices and behaviors.
- CRNAs and students have the responsibility, accountability, and competence to make positive choices and improve their physical, mental and spiritual well-being.
What makes an impaired provider?
- Abuse- use of a psychoactive substance in a manner detrimental to the individual or society
- Addiction- a primary, chronic DISEASE
- Characterized by:
- Impaired control over drug use
- Compulsion or craving
- Continued use in spite of adverse consequences
What is the scope of the problem of an impaired provider?
- Incidence @ 10%
- Opioids drug of choice
- Fentanyl
- Alcohol
- Cocaine
- Propofol
- Inhalational agents, esp Sevo
What are some patterns of behavior and consequences associated with substance misuse and dependency?
- Comes to work during scheduled time off and loiters around departmental drug supply
- Isolates and withdraws from peers
- Takes frequent bathroom breaks or disappears while on duty
- Expresses desire to take extra call
- Increasing or unexplained tardiness or absenteeism
- Gradual decline in work performance
- Consistently signs out more narcotics than peers
- Displays patterns of inappropriate drug choices and dosages
- Increasing mood liability with frequent, unexplained anger and overreaction to criticism
- Increasing difficulty with authority
- Becomes forgetful, unpredictable, confused, and lacks concentration
- Suffers from frequent illnesses or physical complaints
- Exhibits dishonesty, often over trivial or unimportant matters
- Makes elaborate excuses
- Suffers from tremors or “Monday morning shakes”
- Reveals evidence of alcohol or drug use, such as odor of alcohol on breath, heavy perfume or mouthwash, wearing long sleeves
- Appears intoxicated at social functions
- Is discovered comatose or dead
