Operating room safety

OPERATING ROOM SAFETYDR. ANKIT MADHARIA

JUNIOR RESIDENT, DEPARTMENT OF ORTHOPAEDICS

LATA MANGESHKAR HOSPITAL, NAGPUR

OutlineWhy talk about OR safety?Do we have a problem?Is there anywhere we can look for help?Is there a “Culture of Safety”?

As surgeons, what do we want the operating room to be? EfficientEasy access to schedule casesHave the supplies and instruments we need when we need themSafe

Who’s safety are we talking about? Su

rgic

al te

am Surgeon

Nursing staff

Anaesthetist

Attendants

Patient’s safety

How do we benefit from surgery that is safe for our patientsLess morbidity and mortality Improved quality of our work Less liabilityGreater efficiency

Operating Room Errors:× Wrong patient × Wrong operation × Wrong site or side× Unexpected intra-operative death

× Intra-operative complications

× Retained foreign bodies

× Operating room fires × Mishandling of surgical specimens × Patient injury due to positioning or burns × Medication errors × Transfusion mishaps

× Injury to the surgical team members

When is our patient safe in the OR? Never – errors can and do occur !!

◦To Err is Human…..

Hazards in operating room•Blood/body fluid exposures from sharps

•Exposure to released particulates

•Exposures to waste anesthetic gases

•Possible exposures to chemical cleaning agents Slips/trips/fall

hazards

•Exposures to lasers/ X-ray Radiations

•Hitting heads on OR lights

•Electrical shock hazards

•Fires

Blood/Body Fluid Exposures50% of our sharps injuries occur during use. Procedures with the most sharps injuries:SuturingBlood samplingIntradermal injectionsCutting (Scalpel injuries)Inserting IV Lines

Blood/Body Fluid Exposures50% of our sharps injuries occur after use. Procedures with the most sharps injuries:Withdrawing needle from patientDuring clean up and disassemblyDuring disposalOverfilled sharps container, Protruding needles

Needles left in dustbin, laundry, OT Table , on the floor

Blood/Body Fluid Exposures What can we do to prevent these exposure injuries?Utilize safe zone during each surgical procedureAccount for all sharps usedDispose off sharp in sharps container immediately after useWhen emptying suction canisters, always pour carefully and wear eye/face protectionUse personal protective equipment(PPE)

Blood/Body Fluid Exposures Should an exposure occur:For face/ eye exposure: Rinse with water

for about 15 minutesFor needle-stick injuries: Express blood from stick wash with soap and water or betadine. Spirit/sterillium NOT to be used.

Particulate releasesSome procedures in the OR generate particulates into the air (i.e., from cauterizing blood vessels, using lasers)These particulates can have viable organisms present that can cause infectionsPreventive actions:Use suction close to point of generationWear tight fitting safety gogglesWear N95 respirator

Waste Anaesthetic GasesReleases of anaesthetic gases into an OT can result in loss of small motor skills, slowing of reflexes, metal confusion, tiredness Action by the anaesthesiologist can minimize these exposures: Check all connections before use for leaks Pack endotracheal tube to prevent leaks Have equipment serviced/checked periodically

Slips/Trips/FallsThe walking surface of OT locations can be slippery, causing an injuryTake the appropriate precautionsWear slip resistant foot wearReport water/fluids on floor for clean upHave personnel place a “CAUTION – WET FLOOR” sign on floor until cleaned

X-rays , Lasers We must prepare the OT for use of X-Rays/ Lasers Place Lead aprons / lead thyroid shield at the entry

of OT to be used by everyone inside the OT Place the eye protection equipment at the entry of

OT if Laser is to be used, Verify that personnel entering the OT have

adequate protection on Keep the use of C-arm to the minimum

Head injuriesOT lights are adjustable. Sometimes they may be in a position that can cause a head injury.Use these simple rules: Keep light up, out of the way until neededOnce done using, move the light up, out of

the way

Electrical ShocksShocks are usually the result of faulty equipmentTake the following actions: Unplug power cords by holding the plug, never pull

the cordNever operate equipment if the ground plug is

missing. Take the unit out of service for repairs Prevent exposure of electrical equipment from

body fluids/ Other electrolytes inside the OT

FireIn order to understand how fire extinguishers work, you first need to know a little bit about fire.

Essentially, fire extinguishers put out fire by taking away one or more elements of the fire triangle.

Pressure injuries to patientAnaesthetised patient is prone to pressure injury It can be prevented by:Proper patient positioningAdequate paddingPreventing generation of pressure points

Safety Success story Commercial Airline Industry

Tenerife – the crash that changed the airline industry Deadliest crash in aviation history: 538 Fatalities 1977, Tenerife island, Canary islands Collision of KLM Boeing 747 and Pan Am Boeing 747

Tenerife – the crash that changed the airline industry Cockpit KLM 747•Captain Jacob van Zanten – A Star pilot•Copilot- First officer•Flight Engineer- Second officer

Dense fog, one runwayPan Am 747 on runway, out of sight of KLM 747

Tenerife – the crash that changed the airline industry

Captain Co-Pilot

Captain puts KLM plane on runway and is in a rush to take off


Captain Co-Pilot

Wait, we do not have clearance yet!

With great hesitation


Captain Co-Pilot

Air traffic control clearance given but takeoff clearance not given and captain begins throttling up


Captain Co-Pilot

Copilot rushes to try and get clearance, communication is poor with tower but co-pilot gives pilot the OK to takeoff.


Captain Co-Pilot

Copilot focuses on his duties to assist the captain and says nothing


Captain Co-Pilot

At 45 knots, the very junior flight engineer speaks up lightly and says

Is he not clear then, the Pan Am Flight engineer


Captain Co-Pilot

At 45 knots, the very junior flight engineer speaks up lightly and says


What? What?


Captain Co-Pilot

At 80 knots, the flight engineer repeats in a soft voice



Captain Co-Pilot

At 80 knots, the flight engineer repeats in a soft voice


What!


At 112 knots, the captain sees Pan Am 747 sideways on runway and tries to leapfrog over the plane…..collision occurs….538 fatalities

WHY? Several factorsMyth: senior airline captains are failsafe ; avoiding mistakes due to their experience, and wits. Assumption - a person of such stature is presumed to be perfect Culture of the airline cockpit before TenerifeMisunderstood words or phrases Lack of communication

Response 1978 – NASA research indicates that majority of airline disasters NOT due to pilots lack of technical skill or mechanical failure BUT from errors associated with breakdowns in: CommunicationLeadershipTeamwork

Response Cockpit Resource Management (CRM) evolved:oFocus on human and systems issuesoWork culture within cockpit gradually modified oAll members of crew empowered to provide feedback, opinion, ask questions, “hard stop” oError management oStandardized checklists, forcing functions and language of cockpit communications

Another example: Comair flight 5191,

Attempted take off from wrong runway resulting in crash Crash Report:

◦“The flight crewmembers failed to recognize that they were initiating a take off on the wrong runway because they did not crosscheck and confirm the airplane’s position on the runway before takeoff and they were likely influenced by confirmation bias.”

Another example: Comair flight 5191,

Attempted take off from wrong runway resulting in crash

Crash Report: ◦ “The flight crew’s noncompliance with

standard operating procedures, including the captain’s abbreviated taxi briefing and both pilots’ non-pertinent conversation, most likely created an atmosphere in the cockpit that enabled the crew’s errors.”

THINK ABOUT THIS… Technical excellence alone does not always guarantee a positive outcome

Being a good leader and getting the most from a team are not directly linked to your technical expertise

The Impact of Crew Resource Management (CRM) on the Commercial Airline Industry Improved cockpit team interactions Fewer errors Better morale Commercial flight more cost effective Overall rate of airline incidents has declined Commercial aviation is the safest form of transportation on a per mile basis

Airline cockpit and the operating room

Airline cockpit and the operating room

Similarities: High riskHighly complex technical workIntelligent motivated peopleTeams

Differences: Airline pilots have strict duty hoursPilots avoid punishment if they

promptly report errors, surgeons fear litigation and loss of registration

Airlines learned long ago that certain weather conditions make a safe landing unlikely….surgeon tend to operate on anyone they want to !!

What makes an OR safer?

Less Errors

OR Safety Pyramid

Errors that cause harm

ErrorsNear misses

Process problems

These we all hear about

Our OR needs to have a system to capture these

Our OR needs to capture signals that tell us we may have these

Errors depend on two kinds of failures: An error of planning An error of execution

“Slips, lapses and mistakes” - part of humanity - exacerbated by anxiety, fatigue and fear

American college of Surgeons - OR Safety and Crew Resource Management (CRM) Applying the aviation model to the operating room

Seven principles (CRM) 1. Command – one final decision maker who must be willing to foster the team and accept responsibility and accountability for their team’s actions.

Seven principles (CRM) 2. Leadership – defined by commanders willingness to let team members exercise their rights and responsibilities to ensure a safe and positive outcome. Although there is only one commander any member of a team can show leadership. Surgeons who encourage teamwork are MORE respected.

Seven principles (CRM) 3. Communication – teams that fail to communicate are doomed to negative results and errors. Adverse OR events often related to poor communication due to factors such as steep hierarchies, stress and cultural differences

Seven principles (CRM) 4. Situational awareness – an effective leader relies on team to promote situational awareness through effective communication about what is occurring.

“Why didn’t you tell me !”

Seven principles (CRM) 5. Workload management – organizing tasks such that there is equitable distribution amongst team members. “Plan the work and work the plan”

Seven principles (CRM) 6. Resource management – optimal use of all information, data, assistance available to the team. Ensuring the presence of needed resources.

Seven principles (CRM) 7. Decision making Collaborative – discouraged in high performance teams Unilateral – fast but is a problem if leader is not aware of all information or makes incorrect decisionConsultative – most effective in high performance teams. Leader must know when to stop gathering data.

WHO Guidelines for safe surgery

What can we do to achieve a “Culture of Safety” in our ORs Commit to safety Focus on safe operations Recognize a high risk situation View safety as a system responsibility with individual accountability

Surgeons provide leadership Encourage teamwork Collect data OR quality and safety committee

Conclusions The airline industry has taught us that: The most experienced, most skilled, most dedicated, most charming pilot (surgeon) can make a bad mistake. Even the best pilot (surgeon) will not be able to single handedly prevent all errors made in the cockpit (Operating room)

Conclusions An optimal error reduction (safety) system involves:A team approach – you cannot do it alone A fair and non-threatening workplace Standardized approaches such as “Time out”Rigorous and real time scrutiny of errors, close calls and near missesDon’t play the blame game - Hold individuals responsible for recklessness and foster personal accountability BUT hold the system responsible for errors. A constant unrelenting desire to improve

Strive for a “Culture of Safety” in our ORsIt’s good for our patients It will minimize OUR chance of getting into trouble It will minimize the chance of someone else getting US into trouble It will make the OR a more efficient place for us to work

Thank you.

Operating room safety

Health & Medicine

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