Patricia C. Seifert

Patient Safety in the Cardiac Operating Room: Human Factors and Teamwork A Scientific Statement From the American Heart Association

The cardiac surgical operating room (OR) is a complex environment in which highly trained subspecialists interact with each other using sophisticated equipment to care for patients with severe cardiac disease and significant comorbidities. Thousands of patient lives have been saved or significantly improved with the advent of modern cardiac surgery. Indeed, both mortality and morbidity for coronary artery bypass surgery have decreased during the past decade (Figure 1).1 Nonetheless, the highly skilled and dedicated personnel in cardiac ORs are human and will make errors. In 1991, Leape and colleagues2,3 estimated that among the 2 million patients hospitalized in New York in 1984, there were 27 179 adverse events that involved negligence; other evidence suggests that up to 16% of hospital inpatients are harmed.4 Gawande and associates5 found that the incidence of surgical adverse events was 12% among cardiac surgery patients versus 3% in other surgical patients; 54% of the adverse events were considered preventable. Of the roughly 350 000 to 500 000 patients who undergo cardiac surgery each year, 28 000 will have an adverse event, and one third of deaths associated with coronary artery bypass graft (CABG) operations may be preventable.6 Figure 1. Change in mortality and stroke rates in patients undergoing isolated coronary artery bypass graft (CABG) surgery, 2000 to 2009. There was a 24.4% and 26.4% reduction in the unadjusted observed operative mortality (2.4% vs 1.9%) and stroke rates (1.6% vs 1.2%), respectively, during the course of the study period. Reprinted from ElBardissi et al1 with permission from Elsevier. Copyright

The Circulating Nurse's Role in Error Recovery in the Cardiovascular OR

Nursing surveillance, an essential component of perioperative practice, includes the detection of and recovery from errors. However, error recovery is considered routine during nursing care and may go under-recognized. This study assessed the types of errors or potential errors that were detected and recovered by the circulating nurse during care of patients undergoing coronary artery or valve surgery. From June to September 2010, perioperative nurses observed 18 surgical procedures. An average of 11.11 errors or incidents occurred per procedure; however, 77% of all incidents were intercepted and the other 23% were either mitigated or ameliorated so no adverse outcomes occurred. This study demonstrates that nurses play an important role in ensuring patient safety and reinforces the necessity of vigilance in the OR, especially in regard to aseptic technique and surgical prepping.

Crisis Management of Fire in the OR

Fire in the OR is a life-threatening emergency that demands prompt, coordinated, and effective interventions. Specific applications of fire protocols and guidelines for perioperative nurses and their interprofessional colleagues may take several approaches. The perioperative nurse’s role is one that can frequently prevent or ameliorate the damaging thermal effects of a fire. For example, to some degree, the nurse can control all three components of the fire triangle: the ignition sources used during surgery (eg, fiberoptic lights, ESU devices), the oxidizers (eg, room air, supplemental oxygen administered during procedures under straight local anesthesia), and the fuel sources (eg, alcohol-based prep solutions). Although all members of the surgical team play an important role, the ability of and the opportunity for the nurse to minimize the risks of fire are important patient safety attributes of the nurse. Team training, rehearsing appropriate actions, and reacting effectively are essential to preparing health care providers to respond in emergent situations and be able to deliver optimal care. In most jurisdictions, any fired--regardless of size--must be reported to the local fire department. Personnel, managers, and administrators should be prepared also for the possibility of participating in postcrisis evaluations by the fire marshal, The Joint Commission, the Occupational Safety and Health Administration, Centers for Medicare & Medicaid Services, and possibly other fire safety-related organizations. Additionally, supplemental information related to investigating a fire is available through the ECRI Institute.28 The ECRI Institute serves as a third-party investigator and can facilitate root-cause analyses, identify whether the crisis ought to be reported and to whom, and assist in restoring clinical operations.

Ethics in Perioperative Practice—Duty to Self

Though often difficult, ethical decision making is necessary when caring for surgical patients. Perioperative nurses have to recognize ethical dilemmas and be prepared to take action based on the ethical code outlined in the American Nurses Associations (ANAs) Code of Ethics for Nurses with Interpretive Statements. In this fifth of a nine-part series that will help perioperative nurses relate the ANA code to their own area of practice, the author looks at the fifth statement, which emphasizes commitment to ones self.

Ethics in Perioperative Practice-Commitment to the Patient

Though often difficult, ethical decision making is necessary when caring for surgical patients. Perioperative nurses have to recognize ethical dilemmas and be prepared to take action based on the ethical code outlined in the American Nurses Associations (ANAs) Code of Ethics for Nurses with Interpretive Statements. In this fourth of a nine-part series that will help perioperative nurses relate the ANA code to their own area of practice, the author looks at the second statement, which emphasizes commitment to the patient.

Crisis Management of Failed Airway in the OR.

1. Discuss common areas of concern that relate to perioperative best practices when managing the can’t-intubate, can’t-oxygenate scenario. 2. Discuss best practices that could enhance safety during crisis management of a failed airway. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care for difficult or failed airway crisis in the perioperative setting.

Communication and Safety

C O c w t e s q u i l S a t Years ago, if you were asked “What is the most frequent cause of error in the OR?” you would probably have had to think awhile before answering. If I were to ask the same question today, it would likely take you only nanoseconds to come up with the answer, “Poor communication!” “Error” and “communication” have become inextricably linked since The Joint Commission’s Sentinel Event Alert that warned health care workers about the association between poor communication and patient injury. Since The Joint Commission’s alert, there has been an explosion of research and general interest on the subjects of communication and patient safety. It is especially interesting to consider how our communication—the “exchange of ideas, messages, or information”—is affected by so many aspects of our clinical lives. The articles in this issue of the AORN Journal provide many examples not only of the problems associated with communication but also the many ways in which we communicate with our patients, their family members, and our colleagues.

Crisis Management of Air Embolism in the OR

An air embolism in the OR is a life-threatening emergency that demands prompt coordinated interventions by all perioperative team members. Specific applications of protocols and guidelines, such as the flowchart provided in this article, provide key components of traditional and effective responses to surgical crises. Successful management of an air embolism event requires critical skills of perioperative nurses who must consider both the risks for VAE or AAE and preventive actions, be aware of the resources available during an air embolism in the OR, and collaborate with their team members through precise and accurate communication.

Patients' Trust In Nurses' Care

N W a The theme for National Nurses Week, May 6 to 12, 2011, is “Nurses Trusted to Care.” These two concepts, trust in nurses and care of patients, have become entwined in the nursing profession’s DNA. Consider nursing’s 11 years as the most trusted profession in America according to the yearly Honesty and Ethical Standards of Professions Gallup Poll (81% of respondents in 2010 rated nurses “very high/high”). The one year when nurses were not the top-rated profession, 2001, was the year that firefighters were recognized for their heroism and sacrifices after the September 11th terrorist attack on the United States. The level of care provided by nurses was also highly rated in Gallup’s Health and Healthcare Survey (88% of responses in 2010 rated nursing care “excellent/good,” slightly higher than the rating for physician care). One Gallup rating scale particularly intrigued me: the consistently high percentage of “excellent/good” ratings of nurses by individuals in all age groups: 18 to 44 years, 45 to 64 years, and 65 years and older. The ratings among the three groups were 87%, 88%, and 87%, respectively. The high levels of confidence in nurses reported by members of different age groups is notable. The public trusts us. This has become an accepted assumption. I wonder, however, whether we should not ask the obvious question, “Why?” This question may raise hackles and cause indigs

Ethics in perioperative practice--duty to foster an ethical environment.

Though often difficult, ethical decision making is necessary when caring for surgical patients. Perioperative nurses have to recognize ethical dilemmas and be prepared to take action based on the ethical code outlined in the American Nurses Associations (ANAs) Code of Ethics for Nurses with Interpretive Statements. In this sixth of a nine-part series that will help perioperative nurses relate the ANA code to their own area of practice, the author looks at the sixth statement, which emphasizes the nurses duty to promote a working environment that enhances quality patient care and fosters the values and behaviors that form the foundation of ethical practice.