Patient Safety

What is patient safety?

The discipline of patient safety is the coordinated efforts to prevent harm to a patient during the process of healthcare. Over the past ten years, patient safety has been increasingly recognized as an issue of global importance, but much work remains to be done.

Safety in Surgery

Surgical safety is a concern for all of us. Issues may arise as a result of human factors or problems with surgical devices.

• Patient Safety Goals
• Universal Protocol

If you have anything to report about issues to do with human factors, please visit the CORESS (a Confidential Reporting System for Surgery) website. CORESS is an independent charity receives confidential incident reports from surgeons and theatre staff. These confidential reports are analysed and published in surgical literature to educate fellow surgeons, and to reduce the chances of a similar incident re-occurring in another theatre.

If you have anything to report about issues to do with surgical devices, please visit the MHRA (Medicines and Healthcare products Regulatory Agency) website. MHRA is the government agency which is responsible for ensuring that medicines and medical devices work, and are acceptably safe. The MHRA is an executive agency of the Department of Health.

Patient Safety Goals

Goal 1 – Improve the accuracy of patient identification

• Use at least two identifiers when providing care, treatment and services.
• Eliminate transfusion errors related to patient misidentification.

Goal 2 – Improve the effectiveness of communication among care givers

• Report critical results of tests and diagnostic procedures on a timely basis.

Goal 3 – Improve the safety of using medications

• Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.
• Reduce harm associated with anticoagulation therapy.
• Maintain and communicate accurate patient medication information.

Goal 4 – Reduce the risk of health care-associated infections

• Comply with hand-hygiene guidelines of CDC or WHO.
• Prevent infections due to multi-drug-resistant organisms.
• Prevent central-line-associated blood stream infections.
• Prevent surgical site infections.
• Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTIs)

Goal 5 – Reduce the risk of falls

• Implement a fall reduction program.

Goal 6 – Prevent health care-associated pressure ulcers

• Assess and periodically reassess resident risk for pressure ulcers and take actions to address any identified risks.

Goal 7 – The organization identifies safety risk inherent to the patient population

• Identify patients at risk for suicide.
• Identify risks associated with home oxygen therapy.

Goal 8 – Prevent mistakes in surgery

• Make sure that the correct surgery is done on the correct patient and at the correct place on the patient's body.
• Mark the correct place on the patient's body where the surgery is to be done.
• Pause before the surgery to make sure that a mistake is not being made.

Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery

Speak UP

1. Conduct a pre-procedure verification process.
2. Mark the procedure site.
3. Perform a time-out before the procedure.

1. Conduct a pre-procedure verification process

Address missing information or discrepancies before starting the procedure.

(a) Verify the correct procedure, for the correct patient, at the correct site.

(b) When possible, involve the patient in the verification process.

(c) Identify the items that must be available for the procedure.

(d) Use a standardized list to verify the availability of items for the procedure. (It is not necessary to document that the list was used for each patient.) At a minimum, these items include:

• Relevant documentation; examples: history and physical, signed consent form, pre-anaesthesia assessment
• Labelled diagnostic and radiology test results that are properly displayed; examples: radiology images and scans, pathology reports, biopsy reports
• Any required blood products, implants, devices, special equipment

Match the items that are to be available in the procedure area to the patient.

2. Mark the procedure site

At a minimum, mark the site when there is more than one possible location for the procedure and when performing the procedure in a different location could harm the patient.

(a) For spinal procedures: Mark the general spinal region on the skin. Special intra-operative imaging techniques may be used to locate and mark the exact vertebral level.

(b) Mark the site before the procedure is performed If possible, involve the patient in the site marking process.

(c) The site is marked by a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed.

(d) In limited circumstances, site marking may be delegated to some medical residents, physician assistants (PA), or advanced practice registered nurses (APRN).

(e) Ultimately, the licensed independent practitioner is accountable for the procedure – even when delegating site marking.

(f) The mark is unambiguous and is used consistently throughout the organization.

(g) The mark is made at or near the procedure site.

(h) The mark is sufficiently permanent to be visible after skin preparation and draping.

(i) Adhesive markers are not the sole means of marking the site.

(j) For patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site (see examples below): Use your organization's written, alternative process to ensure that the correct site is operated on. Examples of situations that involve alternative processes:

• Mucosal surfaces or perineum
• Minimal access procedures treating a lateralized internal organ, whether percutaneous or through a natural orifice
• Teeth
• Premature infants, for whom the mark may cause a permanent tattoo

3. Perform a time-out

The procedure is not started until all questions or concerns are resolved.

(a) Conduct a time-out immediately before starting the invasive procedure or making the incision.

(b) A designated member of the team starts the time-out.

(c) The time-out is standardized.

(d) The time-out involves the immediate members of the procedure team: the individual performing the procedure, anaesthesia providers, circulating nurse, operating room technician, and other active participants who will be participating in the procedure from the beginning.

(e) All relevant members of the procedure team actively communicate during the time-out.

(f) During the time-out, the team members agree, at a minimum, on the following:

• Correct patient identity
• Correct site
• Procedure to be done

(g) When the same patient has two or more procedures: If the person performing the procedure changes, another time-out needs to be performed before starting each procedure.

(h) Document the completion of the time-out. The organization determines the amount and type of documentation.