QUALITY OF CARE AND PATIENT SAFETY

Question 1

What is the principle of nonmaleficence in regard to patient safety?

Answer 1

Nonmaleficence is a basic tenet of medical ethics based on the Latin primum non nocere, or “first, do no harm.”

Question 2

What elements constitute The Joint Commission National Patient Safety Goals andhow often are these updated?

Answer 2

The Joint Commission National Patient Safety Goals are updated yearly, and for 2010 include the following:
a. Improve the accuracy of patient identification
b. Improve the effectiveness of communication among caregivers
c. Improve the safety of using medications
d. Reduce the risk of health care–associated infections
e. Accurately and completely reconcile medications across the continuum of care
f. Reduce the risk of patient harm resulting from falls
g. Reduce the risk of influenza and pneumococcal disease in older adults
h. Reduce the risk of surgical fires
i. Encourage patients’ active involvement in their own care as a safety strategy
j. Prevent health care–associated pressure ulcers
k. Identify safety risks inherent in the organization’s patient population
l. Improve recognition and response in a patient’s condition
m.Universal Protocol: Prevent wrong person, wrong site, wrong procedure surgery

Question 3

What is the triad of excellence in health care in the authors’ opinion?

Answer 3

In the authors’ opinion, (1) patient safety, (2) improved outcomes, and (3) improved patient satisfaction with their care constitutes the triad of excellence in clinical care.

Question 4

What is included in assessing quality of care

Answer 4

Quality of care includes not only the clinical care indicators, but also the measures of efficiency, such as timely starts, short turnaround times between cases, appropriate access for emergencies, and effective utilization of the ORs, equipment, and staff.

Question 5

What resources are available to measure quality and efficiency in the operating room (OR)?

Answer 5

The American Association of Clinical Directors has developed a Procedural Times
Glossary to measure and compare OR efficiency benchmarks. The ASA also
established the Anesthesia Quality Institute (AQI) in 2009 to establish standardized
quality measures, promote research, and obtain useful data to improve the
quality of patient care.

Question 6

Why is anesthesiology often considered a leader in systematic improvement of
patient safety in the OR?

Answer 6

Anesthesiology has often been cited as an example of how a medical specialty has
systematically improved patient safety. In 1954, Beecher and Todd’s review of
mortality during anesthesia found a mortality rate of 1 in every 1561 operations,
and was one of the first studies to scientifically identify and quantify risks
associated with anesthesia. Patient safety efforts have included features on the
anesthesia delivery systems used in patient care (e.g., Pin Index Systems), founding
of the ASA Closed Claims Database in 1985, and establishment of the Anesthesia
Patient Safety Foundation (APSF) also in 1985

Question 7

What are examples of common safety features on anesthesia machines that promote
the safe delivery of anesthesia?

Answer 7

Many of the features of the anesthesia machine, such as Pin Index Safety Systems,
oxygen fail-safe controls, prevention of hypoxic mixtures, and elimination of
hanging bellows, were developed to enhance patient safety by avoiding critical
technical failures.

Question 8

What is the American Society of Anesthesiologists (ASA) Closed Claims Database?

Answer 8

In 1985 the ASA established the Closed Claims Database with the goal of reviewing
closed malpractice claims to identify sources of technical failure and human error that lead to patient injury, and to then share this information with the
anesthesia community

Question 9

What changes in practice have resulted, in part, from the findings of the ASA Closed
Claims Database?

Answer 9

Initial findings from the Closed Claims Database found that most claims were due to
unrecognized esophageal intubation or other reasons for inadequate oxygenation.
This finding accelerated the requirement for pulse oximetry and capnography as
standard monitors for patients undergoing general anesthesia. Several additional
ASA task forces, such as the Postoperative Visual Loss Registry, have been established
to further address concerns identified by analysis of the Closed Claims Database.
Further analysis of problemsidentified by the Closed ClaimsDatabase hasled theASA
to publish clinical practice recommendations such as the ASA Difficult Airway
Algorithm. The ASA currently has 23 practice advisories available

Question 10

What are the goals of the Anesthesia Patient Safety Foundation and who does it
include?

Answer 10

The Anesthesia Patients Safety Foundation is an independent, nonprofit corporation
with the goal that “no patient shall be harmed by anesthesia.” Board members
include anesthesiologists, nurse anesthetists, equipment manufacturers, lawyers,
and engineers. Its current mission statement identifies safety research and
education, patient safety programs and campaigns, and national and international
exchange of information and ideas as its continuing goals. Its quarterly newsletter is
the most widely circulated anesthesia publication in the world, providing a forum to
publicize advances in technology, as well as concerns regarding medications,
patient issues, and common anesthesiology practices.

Question 11

. What are estimates of mortality from anesthesia in today’s surgical population?

Answer 11

Through the implementation of technical advances and practitioner education,
mortality from anesthesia has improved to 1:250,000. However, as the
population has aged and patients with more severe medical problems are
undergoing surgery, mortality for the very ill is reported to be as frequent as
1:10,000 to 1:1500. (748)

Question 12

12. What broad types of medical or health care errors exist?

Answer 12

Health care errors may be errors of commission (doing the wrong thing),
omission (not doing the right thing), or execution (doing the right thing incorrectly).
A defect in the delivery of care to a patient resulting in an unintended health
care outcome is deemed a health care or medical error.

Question 13

What is an adverse event?

Answer 13

An adverse event refers to any injury caused by medical care. Identifying something
as an adverse event does not imply error, negligence, or poor quality of care.
It simply indicates that an undesirable clinical outcome resulted from some aspect of
diagnosis or therapy, not an underlying disease process

Question 14

What is a sentinel event?

Answer 14

A sentinel event is an unexpected occurrence involving death or serious
physical or psychological injury, or the risk thereof. Serious injury specifically
includes loss of limb or function. The phrase “or the risk thereof” includes any
process variation for which a recurrence would carry a significant chance of
a serious adverse outcome. Such events are called “sentinel” because they signal
the need for immediate investigation and response.

Question 15

What are the most commonly reported sentinel events?

Answer 15

From January 1995 through December 2009, The Joint Commission reviewed
6600 sentinel events; 68% of sentinel events included patient mortality. Among the
10 most frequently reported sentinel events were wrong site surgery (most
common, 13.5%), operative/postoperative complication, medication error, and
unintended retention of a foreign body.

Question 16

. What is a root cause analysis (RCA)?

Answer 16

A Root Cause Analysis (RCA) is a structured process for identifying the causal or
contributing factors underlying adverse events or critical incidents

Question 17

How many patients die annually as the result of medical errors?

Answer 17

The Institute of Medicine’s reports “To Err Is Human: Building a Better
Health System” (November 1, 1999) and “Crossing the Quality Chasm: A New Health
System for the 21st Century” (March 1, 2001) indicated that 98,000 patients in
the United States die annually as a result of medical errors.

Question 18

What is the National Surgical Quality Improvement Program (NSQIP)?

Answer 18

NSQIP began at the Veterans Administration hospitals and has expanded
through the American College of Surgeons to many private institutions. The NSQIP
initiative endeavors to improve the delivery of medical care at a systems level
rather than at an individual level and is credited with improving postoperative
surgical mortality by up to 31% and morbidity by 45%. NSQIP has demonstrated that
while obvious errors can be detected on the local (hospital) level, subtle systems errors
or deficiencies cannot be appreciated without comparison to data from peer
institutions.

Question 19

What are the primary tenets of the NSQIP?

Answer 19

NSQIP has identified three important patient safety observations:
a. Safety is indistinguishable from overall quality of surgical care and should not
be addressed independently of surgical quality.
b. During an episode of surgical care, adverse outcomes, and hence patient safety,
are primarily determined by the quality of systems of care.
c. Reliable comparative outcome data are imperative for the identification of system
problems and the assurance of patient safety from adverse outcomes.

Question 20

What is the central venous catheter checklist advocated for use in intensive care
units (ICUs)? What is the evidence for its efficacy?

Answer 20

The checklist requires that practitioners should:
a. Wash their hands with soap.
b. Clean the patient’s skin with chlorhexidine antiseptic.
c. Put sterile drapes over the entire patient.
d. Wear a sterile mask, hat, gown, and gloves.
e. Put a sterile dressing over the catheter site.
f. In a 2003 Michigan study, the median rate of ICU catheter-related
bloodstream infections decreased by 68%. In the first 18 months, the authors
estimated that 1500 lives and $100 million were saved. These results were
sustained for almost 4 years.

Question 21

What is The Joint Commission?

Answer 21

The Joint Commission is an independent, not-for-profit organization, which
accredits and certifies health care organizations and programs in the United States.
The organization’s mission statement is “to continuously improve health care for
the public, in collaboration with other stakeholders, by evaluating health care
organizations and inspiring them to excel in providing safe and effective care of the
highest quality and value

Question 22

How does The Joint Commission operate?

Answer 22

The Joint Commission conducts unannounced surveys of hospitals on a regular
basis with the goal of assessing structural attributes, policies, and staff to
ensure patient safety and quality of care. The Department of Health and Human
Services and the Center for Medicare and Medicaid Services recognizes The
Joint Commission’s accreditation as deeming hospitals, laboratories, and
other medical care providers able to participate in Medicare and Medicaid
programs.

Question 23

23. What is the definition of wrong-site surgery?

Answer 23

By definition, wrong-site surgery involves all surgical procedures performed on the
wrong patient, wrong body part, wrong side of the body, or the wrong level of a
correctly identified anatomic site. This includes anesthesia procedures such as
regional or neuraxial blocks.

Question 24

. Is the incidence of wrong-site surgery increasing or decreasing?

Answer 24

According to The Joint Commission, the reports of wrong-site surgery or
procedures are steadily increasing. The actual incidence of wrong-site surgery is
unknown but is estimated to be 1:15,000 to 1:112,000.

Question 25

What steps has The Joint Commission taken to prevent wrong-site surgery?

Answer 25

5. To prevent the occurrence of wrong-site surgery, The Joint Commission has issued a
   universal protocol which requires:
   a. Preoperative verification that uses two patient identifiers as well as the
   procedure, the site/side or vertebral level, and involves at least two health
   care providers (one of whom is the surgeon)
   b. Site marking of the operative site by the surgeon using his or her initials or “yes”
   with patient involvement
   c. “Time-out” right before starting the procedure (

Question 26

What are the essential elements of a preprocedural “time-out”?

Answer 26

The process of “time-out” is when all the services involved in caring for the patient
(surgery, anesthesiology, and nursing) pause before beginning a procedure to
ensure that the correct patient is undergoing the correct procedure on the correct
location and all the necessary imaging studies and equipment necessary to safely
complete the procedure are available. The essential elements for a preprocedural
“time-out” are:
a. Identification of the patient using two identifiers
b. Correct side/site
c. Correct procedure
d. Correct position
e. Verification that implants, devices, and special equipment are available
f. Relevant images are properly labeled and displayed
g. Allergies
h. Antibiotics administered
i. Safety precautions based on fire, hazards, patient history, or medication use
j. Verbal agreement that all time-out elements have been met (

Question 27

How do the National Patient Safety Goals suggest that patient identification be
confirmed?

Answer 27

National Patient Safety Goals have focused on improving patient identification
by checking two independent identifiers, such as name and date of birth or name
and medical record number.

Question 28

When should patient identifiers be checked?

Answer 28

These patient identifiers must be checked every time a patient is to undergo
a diagnostic test or procedure, or is to receive medication or blood products.

Question 29

What constitutes a “handoff” of patient care?

Answer 29

When a patient is transferred from the care of one practitioner to another,
whether it is from floor nurse to the anesthesiologist in the operating room,
anesthesiologist to postanesthesia care unit nurse, or within services from daytime
team to an on-call team, structured systems to facilitate the transfer of vital
patient information are essential to avoid errors. The Joint Commission
has termed these transfers of patient care as “handoffs.”

Question 30

What is SBAR communication?

Answer 30

Originally developed for U.S. Navy communications, situation-background-
assessment-recommendation (SBAR) has been adapted by many health care
organizations and is internationally accepted as an effective communication
regarding a change in a patient’s condition either from nurse to physician or
among physicians. The elements of SBAR communication are:
Situation: The notifying health care practitioner identifies the patient and the
problem or the change in the patient’s condition.
Background: Relevant background information specific to the situation. For
example, this could include the patient’s diagnosis, his mental status, current vital
signs, complaints, pain level, and physical assessment findings.
Assessment: This step of the communication provides the practitioner with the
opportunity to offer an analysis of the problem or to convey more extensive data
about the patient, such as changes from prior assessments.
Recommendation: What the practitioner believes would help resolve the
situation or what is the desired response.

Question 31

What is medication reconciliation in the context of anesthesia?

Answer 31

Medication reconciliation refers to the process by which the medications
the patient is on preoperatively are reviewed for any possible adverse
reactions with any medications he or she might receive intraoperatively or
postoperatively.

Question 32

When should medication reconciliation be performed?

Answer 32

Medication reconciliation should occur whenever the patient is admitted,
transferred to another unit or service, or is discharged home

Question 33

How should medication labeling be performed in the OR?

Answer 33

Medications should not be drawn into syringes until immediately prior to patient
use and the syringes must be labeled with the drug name, drug concentration,
and time medication is drawn up. Anesthesiologists have long adopted the use of
color-coded labels to distinguish among different classes of medications in an
effort to avoid medication administration errors

Question 34

When should medication labeling be performed in the OR?

Answer 34

The Joint Commission recommends against the labeling of empty syringes in
anticipation of future medication preparation since this does not obviate drawing
the incorrect medication into a differently labeled syringe. A clarification on this
recommendation was sought by the ASA, in response to which The Joint
Commission will remove it from the FAQ section of their website. However, they
have stopped short of a clear statement of reversing it

Question 35

What elements of proper medication name and doselabeling help ensure patient safety?

Answer 35

Additional requirements in ensuring medication safety are avoiding the use of
abbreviations with regard to drug name and unit of dose. The use of decimal points
followed by a trailing zero is also to be avoided while a zero must be placed in
front of a decimal point to avoid dosing errors. Finally, the Do Not Use List prohibits
the use of “u” for units, “iu“ for international units, and Q.D. or Q.O.D. for
daily or every other day dosing.

Question 36

How can look-alike and sound-alike drugs be differentiated?

Answer 36

Care must be taken to avoid using vials of drugs from manufacturers that look alike.
If look-alike drugs cannot be avoided, such vials should not be placed near one
another in any pharmacy drawer. In addition, TALLman lettering, such as
EPInephrine may be used to distinguish it from EPHedrine

Question 37

What elements are requisite for a surgical fire and what are their sources in the OR?

Answer 37

For a fire to start, each element of the fire triangle—heat, fuel, and oxygen—must be
present. Heat is the by-product of electrocautery units, lasers, and endoscopes.
Paper drapes, fabric towels, and gauze sponges provide ample fuel. Oxygen is often
present at high concentrations in localized areas such as during facial plastic
surgery or tracheostomy. Also, the newer, more effective skin preparation solutions
often contain alcohol that is highly flammable and must be allowed to dry
completely prior to placement of surgical drapes

Question 38

What steps can be taken to prevent OR fires?

Answer 38

Effective communication between all perioperative team members is essential
in preventing OR fires. Skin preparation solutions must be completely dried
prior to surgical draping, and lasers and endoscopes should be turned off or to
standby when not in use. When there is a possibility that oxygen may come
into direct contact with electrocautery, as in airway surgery or when
administering oxygen in a non-closed circuit, oxygen should be administered at
the lowest possible concentrations necessary for the patient to maintain
oxygenation. Use of special endotracheal tubes may also be warranted in some
cases.

Question 39

What practices can help limit hospital-acquired infections?

Answer 39

Prevention of hospital-acquired infections requires strict adherence to hand
hygiene protocols, prevention of central line, and surgical site infections, and
prevention against the spread of multidrug resistant organisms. Interventions by
anesthesia providers may include appropriate selection of antibiotics, timely
administration and dosing of antibiotics, proper hygiene and sterile technique
where indicated, appropriate contact and respiratory precautions, and maintenance
of normothermia

Question 40

What is the Surgical Care Improvement Project (SCIP)?

Answer 40

The Surgical Care Improvement Project (SCIP) is a national partnership of
organizations interested in improving surgical care by significantly reducingsurgical complications. The steering committee is comprised of 10 national
organizations who have pledged their commitment and full support for SCIP:
a. Agency for Healthcare Research and Quality
b. American College of Surgeons
c. American Hospital Association
d. American Society of Anesthesiologists
e. Association of Perioperative Registered Nurses
f. Centers for Disease Control and Prevention
g. Centers for Medicare & Medicaid Services
h. Institute for Healthcare Improvement
i. The Joint Commission
j. Veterans Health Administration

Question 41

What are the current SCIP quality measures?

Answer 41

Current SCIP quality measures include the following evidence-based outcome
improvement interventions:
a. Prophylactic antibiotic received within one hour prior to surgical incision
(quinolones or vancomycin may be administered within 2 hours)
b. Prophylactic antibiotic selection for surgical patients
c. Prophylactic antibiotic discontinued 24 hours after surgery end time (48 hours
for cardiac surgery)
d. Cardiac surgery patients with controlled 6 AM postoperative serum glucose
(<200 g/dL)
e. Surgery patients with appropriate hair removal (depilatory creams or clippers
only, no razor)
f. Urinary catheter removed on postoperative day 1 or postoperative day 2
g. Surgery patients with perioperative temperature management (goal 36.0 C/
normothermia)
h. Surgery patients on a b-blocker prior to admission received b-blockers during
the perioperative period
i. Surgery patients with recommended venous thromboembolism (VTE)
prophylaxis ordered
j. Surgery patients received appropriate VTE prophylaxis within 24 hours before

Question 42

What is a never event?

Answer 42

Never events are 28 occurrences on a list of inexcusable outcomes in a health
care setting compiled by the National Quality Forum (NQF). They are defined as
adverse events that are “serious, largely preventable, and of concern to both the
public and health care providers for the purpose of public accountability.”
The Centers for Medicare & Medicaid Services (CMS) also provides a list of never
events, some of which coincide with the NQF

Question 43

What are the current never events, per CMS?

Answer 43

Per CMS, the list of never events includes:
a. Foreign object left in patient after surgery
b. Surgery on wrong patient
c. Surgery on wrong body part
d. Wrong surgery on a patient
e. Death/disability associated with intravascular air embolism
f. Death/disability associated with incompatible blood
g. Death/disability associated with hypoglycemia
h. Death/disability associated with a fall within facility
i. Death/disability associated with electric shock
j. Death/disability associated with a burn incurred within facility

Question 44

What are the financial ramifications of a never event?

Answer 44

If a never event occurs, CMS will not pay the hospital for the added cost of the extra
care incurred as a result.

Question 45

What are the components of a culture of safety?

Answer 45

A culture of safety enables any member of the health care team to contribute to
patient safety. It is a key component of many high reliability organizations.
Components of a culture of safety include:
a. A blame-free environment where individuals are able to report errors or close
calls without fear of reprimand or punishment
b. An expectation of collaboration across ranks to seek solutions to vulnerabilities
c. A willingness on the part of the organization to direct resources for addressing
safety concerns

Question 46

What is a high reliability organization?

Answer 46

High reliability organizations refers to organizations or systems that operate in
hazardous conditions and have done so with nearly failure-free performance
records, not simply better than average. Commonly discussed examples include air
traffic control systems, nuclear power plants, and naval aircraft carriers. (

Question 47

What are reporting guidelines for adverse events?

Answer 47

Compliance with patient safety initiatives involves either voluntary or
mandatory reporting of adverse events. Reporting requirements are different in
each state and for federal government programs as well. In 2002 Pennsylvania
became the first state to establish a mandatory reporting system for not only
serious adverse events, but “incidents” (near misses) as well.

Question 48

How can OR efficiency be improved by anesthesiologists?

Answer 48

Anesthesiologists can be leaders in facilitating punctuality, on time starts,
keeping turnaround times between cases to a minimum, and promoting expeditious
surgery to improve the utilization of resources in the operating room. A systems
approach and standardization of equipment and processes will not only
streamline operations and improve efficiency but also improve patient safety,
staff satisfaction, and patient satisfaction

Question 49

49. What are the financial considerations of OR time?

Answer 49

The operating rooms are the most expensive units to run in a hospital and, if run
inefficiently, can become a major financial drain. However, when run appropriately,
ORs are also the best source of revenue for most hospitals.

Question 50

What is the link between staff satisfaction and patient satisfaction with health
care?

Answer 50

Surveys have tracked a close link between staff satisfaction and patient satisfaction
at health care facilities. For example, according to the National Surveys (Press
Ganey), about one third of patients surveyed would not recommend the facility
where they received care. Interestingly, about one third of health care employees
at the hospitals surveyed were dissatisfied with their job. It should therefore be
a goal for every facility to promote staff satisfaction and be intolerant of
disruptive behavior so that the safest and best care is rendered to its
patients.