Patient Safety and Perioperative care Flashcards
(21 cards)
what is patient safety
- Everything we do is about patient safety
- as a minimum it is not causing harm and beyond that it is providing the best care possible
What should the health care system do
- prevent errors
- learn from the errors that do occur
- be built on a culture of safety that involves health care professionals, organizations and patients
How do we try and prevent erros
- Have a surgical safety checklist
- entire surgical team goes through the cheklist before anaesthesia, before knife to skin and then before the patient leaves the operating theatre
What happens in the sign in check list
Patient confirms
- site of operation
- identity
- procedure
- consent
- site is marked
- anaesthesia safety check completed
- pulse oximeter on patient and functioning
- does the patient have an allergy
- difficult airway/aspiration risk
- risk of blood loss
What happens in the time out checklist
- all the team members confrim there roles and there name
- surgeon, anaesthesia and nurse verbally confirm the patient, site and procedure
- surgeon reviews - critical or unexpected steps, operative duration, and anticpated blood loss
- anaesthesia team reveiws - are there any patient specific concerns
- nursing team reviews - has sterlity been confirmed and are there equipment issues or any concerns
- antibiotic prophylaxis has been given
- is essential imaging displayed
What happens in sign out
- instruments, sponges and needle counts are all correct
- name of the procedure recordred
- how the specimen is labelled
- whether there are any equipment probblems to be addressed
- reveiw key concerns for recovery and management of the patient
when was the surgical check list introduced
2008
How do you reduce the risk of causing a drug reaction
- red band - alert them to any allergies that they may have
What is a fail safe mechanisms on an anaesthetic machine
- self inflating mask and valve incase the anaesthetic machine breaks
How do you improve human performance
- Use of cognitive aids to avoid reliance on memory (e.g. checklists and protocols) • Double checking drugs & blood
- Reduce distractions & interruptions (e.g. drug rounds)
- Enhance effective team work (so teams less likely to make an error)
What are latent errors
Latent errors are errors which are likely to be made due to systems or routines that are formed in such a way that humans are disposed to making these errors
How do you reduce latent errors
- Provide visual cues (allergy bracelets, colour coding etc)
- Decrease look-alike / sound-alike drugs or equipment, or patients!(2 Mr Smiths)
- Simplify and standardise (e.g. 2222 and 999)
How do you maximsise safety with technology
- Fail-safe self inflating bag valve mask (ambubag)
- USS guided insertion of chest drains and central lines
- Antibiotic prophylaxis in surgery when appropriate
- Pressure relieving mattresses
- Call bells
- Access to information technology (histories, results, reference material etc)
- Part task trainers for surgical skills
- Robotics in surgery
How do you manage crisis
- Fail-safe self inflating bag valve mask (ambubag)
- call bells
How do you improve human responses to crisis
- Simulator training
- human factors training
What do you do when you make an error
- Report the error so that others can learn from it
- All errors are reported regardless of whether any harm has occurred
• they are investigated with a Root Cause Analysis done as required
• preventative measures are put in place
What are the categories of error
- Incidents
- Serious Incidents (SIs)
- Near misses
- Never events
Name the incident reporting system
Datix
What are never events
Never Events are serious largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.
describe an example of an never event
- Unintentional connection of a patient requiring oxygen to air flowmeter
Recommedation
- cap of unnecessary air supplies
- remove airflowmeters when not in use
- fit flaps to airflowmeters
- example of trying to red a latent error in the system
How do you promote a culture of safety
- Avoid the blame game
- report incidents
- listen and learn
- be cognisant of latent errors and human factors
- optimise care wherever possible using QIPs and audits etc
