Reducing Surgical Errors: Implementing a Three-Hinge Approach to Success RONDA LANDERS, DNP, RN
ABSTRACT Surgical errors can have serious consequences including patient deaths, and recent reports suggest that surgical errors continue to occur at unacceptable rates. Studies indicate that causative factors for surgical error include human factors, OR interruptions, staffing issues, and error-reporting trends. A “three-hinge” approach can be used to implement a safety program that emphasizes use of a safe surgery checklist and the Centers for Medicare & Medicaid Services reporting requirements for ambulatory surgery centers. The three hinges are the assignment of a change agent, ideally an RN with a doctorate in nursing practice; team cohesiveness; and continuous quality monitoring. AORN J 101 (June 2015) 657-665. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.04.013 Key words: surgical error, human error, patient safety, safe surgery checklist.
http://dx.doi.org/10.1016/j.aorn.2015.04.013 ª AORN, Inc, 2015
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o one person can ensure a patient’s safety during a surgical event. Rather, patient safety is the responsibility of a cohesive team of skillful and conscientious individuals. Safety considerations are integral to perioperative processes, yet the rate of surgical errors remains high. Factors that affect safety include team cohesiveness, the team’s ability to adapt to change, and sustained adherence to quality improvement measures. This article highlights the problem of surgical errors, presents a brief overview of causative factors, identifies evidence-based best practice interventions, and introduces a “three-hinge” surgical safety program implementation and evaluation model that may help guide surgical teams in making successful changes. Key facets of the safety program are an emphasis on use of a safe surgery checklist and the Centers for Medicare & Medicaid Services (CMS) reporting requirements for ambulatory surgery centers (ASCs).
PROBLEM AND SIGNIFICANCE Two landmark reports published by the Institute of Medicine in 1999 and 2001 provided health care professionals with a wake-up call to increase care quality and safety and reduce costs.1,2 The reports, To Err Is Human: Building a Safer Health System1 and Crossing the Quality Chasm: A New Health Care System for the 21st Century,2 detail health care-related errors and estimate that between 44,000 and 98,000 patients die each year as a result of these errors, many of which are surgery related.1 Although these reports created an increased awareness that has led health care providers to implement various improvements, more than a decade later, concerns remain regarding the number of surgical errors. In 2012, Mehtsun et al3 undertook a rigorous analysis of national malpractice claims and estimated that 80,000 “never events” occurred in US hospitals during the 20-year period between 1990 and 2010. Never events, or sentinel events, are medical errors that result in severe adverse consequences (ie, death or significant disability).4 Mehtsun et al3 retrieved data from the National Practitioner Data Bank, a federal repository of medical malpractice claims. They identified malpractice judgments and out-of-court settlements totaling $1.3 billion related to retained foreign bodies and wrongsite, wrong-procedure, and wrong-patient surgeries. As a result of these errors, 6.6% of patients died, 32.9% experienced permanent injury, and 59.2% experienced temporary injury.3 In 2013, The Joint Commission reviewed 102 incidents of unintended retention of foreign objects; 109 wrong-patient, wrong658 j AORN Journal
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site, wrong-procedure events; and 77 operative/postoperative complications.5 These statistics are alarming considering health care providers’ increased focus on patient safety and quality care during the past decade.
LITERATURE REVIEW Numerous research studies and health care literature reviews identify, establish, and verify factors that heighten the risk for surgical errors. Studies indicate that causative elements include human factors, OR interruptions, staffing issues, and errorreporting trends.
Human Factors “Human performance can be affected by many factors such as circadian rhythms, state of mind, physical health, attitude, emotions, propensity for certain common mistakes, errors and cognitive biases.”6(p21) Human factors in the OR can influence the occurrence of errors that include medication errors; procedural errors; errors involving the wrong site, procedure, or patient; foreign body retention (eg, gauze, sharps, instruments); and errors in execution (eg, inaccuracies in cutting, such as lack of precise direction, length, and depth control). Findings of a research study conducted by Fabri and ZayasCastro7 suggest that human error is the leading cause of surgical error. Their study assessed underlying medical errors that contributed to surgical complications. Medical error data were collected during a 12-month period from 9,830 surgical procedures. Findings showed an overall complication rate of 3.4% (n ¼ 332 patients), of which 78.3% were related to medical errors. Medical errors included
errors in surgical technique (63.5%), judgment errors (29.6%), inattention to detail (29.3%), and incomplete understanding of the problem or surgical situation (22.7%).
In 20% of procedures during which an error occurred, the error was considered to be a mistake (ie, the wrong thing was done), with a high correlation of the error having occurred during evaluation (ie, before the procedure). In 58% of the procedures, the researchers considered the error to be the result of the right thing being done incorrectly, with a high correlation of the error having occurred during execution. System and communication errors each accounted for 2% of errors.7 Fabri and Zayas-Castro found that the most frequent type of error was related to an “error in technique” and “was consistently reported as a slip occurring during execution.”7(p559)
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OR Interruptions Interruptions in the surgical flow can result in poor patient outcomes, near misses, and patient deaths. A 2007 study by Wiegmann et al8 categorized surgical flow disruptions into five categories teamwork/communication failures (ie, lack of team coordination, familiarity, and monitoring), extraneous interruptions, equipment and technology problems, issues of resource accessibility (ie, lack of needed surgical resources), and training-related distractions (ie, failure in management, guidance, or training of OR team members).8 The researchers found that the majority of errors caused by disruption were minor, and approximately 60% of surgical errors were noticed and rectified immediately by the surgical team; 32% of these were events that related to team members’ level of experience or the difficulty performing a specific technique or procedure. Team members did not detect approximately 40% of surgical errors immediately but did recognize and compensate for them at some point during the surgery. Teamwork and communication problems caused 52% of surgical flow disruptions. Rates for other types of disruptions were 17% external and extraneous disruptions, 12% supervisory and training distractions, 11% equipment and technology problems, and 8% resource inaccessibility.8
Staffing Issues Silen-Lipponen et al9 conducted a qualitative study that supported the relationship of teamwork and staffing inadequacies to surgical errors. They interviewed a convenience sample of nurses (N ¼ 30) who worked in surgical departments in three countries: Finland (n ¼ 10), the United States (n ¼ 10), and Britain (n ¼ 10). Data were collected from a larger international research project focused on the phenomena of nursing education and practice in different countries so that broad-range descriptions of OR teamwork could be ascertained. An important objective was to consider best practices for increasing patient safety in the OR. Findings identified potential sources of errors and approaches to error prevention. Findings related to the potential causes of errors concerned nurses’ need to manage multiple and simultaneous demands while at the same time providing safe, quality care. Factors the participants reported that could lead to error included the following: Fear of making an error because the possibility of harsh judgment and humiliation led to nervousness that could contribute to new errors.
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Reducing Surgical Errors
Frequent turnover in teams led to uncertainty in team members’ abilities, mistrust, and concern for patient safety. The threat of overtime work caused by overbooked surgery schedules resulted in pressure to work harder and more quickly. Continuous emotional distress caused by incidents such as arguments during surgeries, hostile behaviors, and the need for nurses to act as intermediaries between other professionals, weakened OR team cohesion. These types of distractions could potentially divert attention from the task at hand or the surgical procedure. Error prevention strategies provided by the respondents included that surgical teams in which members were familiar with each other were more likely to have confidence in each other’s skills and anticipate one another’s needs, creating a calmer atmosphere. Safety issues could be controlled by monitoring to detect and respond quickly to one’s own errors and errors committed by other members of the team and by willingness to provide instruction to others and perform safety checks when required. In addition, surgical scheduling that promoted the optimal order and timing of surgical procedures, continuous interaction and collaboration among members of the team, team member competency, and good management decisions, especially related to staff mix (eg, scheduling an adequate number of experienced staff members to ORs and shifts, considering team members’ levels of education), were factors the nurses believed promoted good teamwork and patient safety. Some research has suggested that having staff-mix ratios with greater numbers of RNs, especially baccalaureate-prepared RNs, may improve patient outcomes. Needleman et al10 suggested that a greater percentage of RNs might increase the quality of patient care, lower mortality rates, and result in overall cost reductions. They used data from 799 nonfederal acute care general hospitals in 11 states and regression analyses that found an association between nurse staffing and several nursesensitive patient outcomes to simulate the following three options to increase nurse staffing: 1. 2. 3.
raising the proportion of nursing hours provided by RNs to the 75th percentile for hospitals below this level, raising the number of licensed (ie, RN, LPN) nursing hours per day to the 75th percentile, and raising staffing to each of these levels in hospitals in which each was below the 75th percentile.
The percentile was based on the researchers’ judgment of the level of staffing feasible for most hospitals.10 Study results suggest that increasing the proportion of RN nursing hours without increasing the total number of nursing hours reduced net hospital costs. Increasing nursing hours, with or
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without increasing the proportion of RN hours, increased hospital costs up to 1.5%; however, an increase in RN hours reduced lengths of stay, adverse outcomes, and patient deaths. These findings suggest that employing a larger number of RNs might improve select nurse-sensitive outcomes and that the cost of employing these RNs could be offset by the reduced incidence of negative patient outcomes. A study by Shamliyan et al11 suggested that increased RN staffing in intensive care units and, to some extent, in surgical units is associated with lower hospital-related mortality and adverse patient events. In addition, a systematic review of international research by Lankshear et al12 showed evidence of a relationship between higher-skill-mix RN staffing and improved patient outcomes. All of these studies indicated a need for additional research specific to surgical staff mix and its relationship, if any, to preventing surgical errors. It would also be advantageous to investigate whether changes in surgical staff mix promote better team cohesiveness and performance.
Error-Reporting Trends Clinical staff members’ fear of reprimand and job loss influences error reporting. Nurses may fear disciplinary procedures because remedies after adverse events often have been focused on the individual and individual behaviors connected to the event.9 Too often, incident reports become specific to the individual who reported the error instead of what could be learned. Murdock13 discussed potential consequences resulting from surgical errors for the perioperative team: feelings of guilt, peer review hearings, licensure stipulations, and malpractice litigation. Malpractice cases related to retained foreign objects are very difficult to defend because of the doctrine of res ipsa loquitur (ie, the thing speaks for itself).13 Cases such as these are considered negligence.13 The main goal of quality improvement efforts should be to identify trends and develop and implement prevention processes to reduce the likelihood of similar errors occurring in the future. If error events are not reported because of fear, there is no opportunity to learn from these events.
EVIDENCE-BASED INTERVENTIONS Mitigating the causes of surgical errors requires implementing evidence-based safety interventions. In 2007, the World Alliance for Patient Safety, an initiative of the World Health Organization (WHO), launched the Second Global Patient Safety Challenge, “Safe Surgery Saves Lives,” to promote improved worldwide surgical care.14 A team of international experts identified four areas of focus for improvement
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surgical site infection prevention, safe anesthesia, safe surgical teams, and measurement of surgical services.14
A result of the safety challenge is the WHO Surgical Safety Checklist, which offers a three-phase surgical team task guide that targets these areas of emphasis. Using the checklist heightens the time-out procedure to a new level of safety by bringing together the members of the surgical team to improve the consistency of performing key safety checks before the induction of anesthesia, before the skin incision, and before the patient leaves the OR (Figure 1).13 In 2012, the CMS released new required reporting standards for ASCs with specific outcome measures to be reported electronically, including use of a safe surgery checklist congruent with the WHO checklist.15 Required reporting measures for the Ambulatory Surgical Center Quality Reporting (ASCQR) Program were included in the Calendar Year (CY) 2012 Outpatient Prospective Payment System ASC final rule.15 The CMS has set time frames for gradual implementation of the program’s eight outcomes (Table 1).15 Eventually, the same CMS guidelines and requirements will transition to all surgery settings, as has been proposed for hospital inpatient facilities for the fiscal year 2016 and beyond.16 One way to translate evidence-based practice (EBP) into clinical recommendations is to develop a safe surgery program with emphasis on using a safe surgery checklist and on the CMS ASCQR reporting requirements. When implementing a safety program, special consideration should be given to long-term adherence and consistency. Interestingly, the literature has focused on factors that influence surgical errors and on measures to counteract error occurrences; however, less emphasis has been placed on the factors that influence surgical teams to accept, implement, and continue to comply with the recommendations. Humans tend to become complacent or automated when performing the same task repetitively. It is well documented that humans perform best during unexpected or unanticipated events; when performing repetitive work, they are more prone to boredom and distraction and error is more likely to occur.17 This phenomenon is typified by the driver who arrives at a routine destination without recalling the details of the journey. The safe surgery checklist should not become another piece of paper for automated box checking, but rather should promote a systematic process that the surgical team performs in a conscientious interactive manner.18 Therefore, it is important to structure a safety program in a way that includes education about the need for change, team member support for change, and continuous monitoring for compliance with new processes.
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Figure 1. World Health Organization Surgical Safety Checklist. Reprinted with permission.
A THREE-HINGE APPROACH TO SAFETY PROGRAM IMPLEMENTATION The “door to success” has been referred to numerous times in various conceptualizations, but if considered in the contextual sense of change, the “door” can be a structural framework for change preparation and implementation. When one arrives at an entrance, little thought is given to the door and its design; most consideration is given to the desired passage. However, successfully opening the door depends heavily on the careful construction of the door itself. Deliberate attention to the three hinges then is imperative for successful operation. The implementation and evaluation of a safe surgery program can be likened to passage through a door in that the success of the program relies on the successful operation of three hinges: (1) a change agent, (2) team cohesiveness, and (3) quality monitoring (Figure 2).
Change Agent The middle hinge is the one most relied on to keep the door securely on the frame. In this approach, the middle hinge is the critical component of selecting the change agent who will most
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effectively set change in motion. Change agents have been described as transformative leaders who possess skills and innate characteristics that inspire people to change.19 The transformative leader as described by Bennis and Nanus19 is an individual who drives people to action and changes followers to leaders, who may then also become agents of change. The middle hinge of the model depicts a nurse with a doctorate in nursing practice (DNP) as an optimal choice for the leadership and oversight of the safety program. A major impetus for the DNP degree can be attributed to implementation of recent health care changes that are especially challenging for the nursing profession, such as advanced technology, new administrative constructs, and expanded professional roles. The primary focus of the American Association of Colleges of Nursing AACN Position Statement on the Practice Doctorate in Nursing is to improve the context within which care is delivered.20 This document states that nurses prepared at the doctoral level with a combination of clinical, organizational, economic, and leadership skills are able to critique nursing research and other clinically scientific findings that significantly influence health care outcomes.20 Melnyk and Fineout-Overholt21 called for mentors with in-depth knowledge AORN Journal j 661
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Table 1. Centers Myth: for Medicare & Medicaid Services Quality of Care Measures Number
1
Measures for Calendar Year (CY) 2014 Payment Determination
Type of Measure
ASC-1
Patient burn
Outcome measure
ASC-2
Patient fall
Outcome measure
ASC-3
Wrong site, wrong side, wrong patient, wrong procedure, wrong implant
Outcome measure
ASC-4
Hospital transfer/admission
Outcome measure
ASC-5
Prophylactic IV antibiotic timing
Process-of-care measure
Measures for CY 2015 Payment Determination ASC-6
Safe surgery checklist use
Web-based measure
ASC-7
ASC facility volume data on selected ASC surgical procedures
Web-based measure
ASC-8
Influenza vaccination coverage among health care workers
Internet-based surveillance managed by the CDC
ASC-9
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average-risk patients
Web-based measure
ASC-10
Endoscopy/polyp surveillance: colonoscopy interval for patients with a history of adenomatous polyps; avoidance of inappropriate use
Web-based measure
ASC-11
Cataracts: improvement in patient’s visual function within 90 days after cataract surgery
Web-based measurea
Measures for CY 2016 Payment Determination
ASC ¼ ambulatory surgery center. a Data submission deadline and payments affected are to be determined. 1. ASC Quality Reporting. Centers for Medicare & Medicaid Services. http://ascrs.org/sites/default/files/ASC%20Specs%20Manual_v3_0c.pdf. Accessed April 28, 2015.
of EBP and organizational change to foster the conscientious use of current best evidence in making decisions about patient care. The nurse with a DNP is trained to consider research along with clinical expertise and patient preferences to make decisions in the clinical setting and help overcome barriers. The DNP is thoroughly prepared, uniquely positioned, and well suited to translate current research and best evidence into the practice setting to enhance health care outcomes. Implementing a safe surgery program that includes a safe surgery checklist and emphasis on the CMS ASCQR program elements requires buy-in from primary stakeholders, including the medical director, chief nursing officer, managers or team leaders, quality improvement director, and members of the surgical team. As the change agent, the DNP nurse will need to gain stakeholder acceptance, approval, and support for best outcomes. Understanding change theory helps the DNP nurse prepare for change implementation and anticipate issues that might arise. Numerous change models offer steps to successfully implement change. Lewin’s change model22 describes change in three phases: unfreeze, change, and refreeze. The first step of change, unfreezing, is the most difficult in the change process because it involves altering 662 j AORN Journal
the status quo. The essential objective is to motivate reaction by delivering a compelling message. Emphasis should be given to facilitating communication within the team, listening to team members’ concerns, and being available to respond quickly to their questions or comments. Reid and Clarke18 provide helpful “myth busters” or answers to questions that staff members are likely to ask related to the safe surgery checklist. For example, Myth: The checklist won’t make a difference, we’re already careful and we have never had a problem. It will just create additional work. Bust: It’s true that the majority of the checks integral to the checklist are already routinely practiced . . . but they are not practiced systematically, consistently and with all essential personnel participating. If they were, a large number of incidents would not have happened. Health care staffs are human beings and human beings make mistakes, regardless of their level of competence, experience and usual vigilance.18(p339)
Team Cohesiveness The leadership provided by the change agent is a key element for building team cohesiveness, another hinge of the three-
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Selection of the initial team should be based on those who are eager to attempt change and are committed to improving workflow.18 The optimal team will have effective communication skills, interdisciplinary collaboration, and the ability to coordinate and prioritize, and team members should be individually experienced in the surgical procedures they are performing.8,9 Most important, the selected team members should exhibit confidence in one another’s skills. Overall, the team members should be familiar with each other and function well together.8,9 Patient safety improvements do not require the same scientific rigor that is seen in research.18 For a quality implementation initiative, Reid and Clarke18 recommend using a model that offers basic methodologies rather than methods used in randomized controlled trialsdfor example, the Plan, Do, Study, and Act (PDSA) Cycle.23 The PDSA Cycle is congruent with Lewin’s phases of change and provides steps for initiating change and continual improvement.23 Planda team identifies a goal for the purpose of change (ie, implementing a safe surgery checklist). Dodthe team implements the elements of the plan (eg, developing or adopting and implementing the safe surgery checklist). Studydthe team monitors outcomes to test the validity of the plan (eg, monitoring and evaluating use of the safe surgery checklist and its functionality); this step is key for assessing success or identifying problems and areas for improvement. Actdthe team integrates the learning achieved in the entire process; this step can also be used for adjusting the goal. Figure 2. The three-hinge approach to safe surgery program implementation. hinge approach. The leader should promote a working culture that cultivates empowerment, communication, and respect among team members. Identifying key players within the surgical staff who are highly skilled and motivated will help launch change initiatives. For example, perioperative nurses may greatly influence the success of using a safe surgery checklist because they are active participants in the surgical time out and most often initiate the process. The safe surgery program and checklist should be implemented with one surgical team on defined days and an integration period allowed until a smooth workflow is achieved. This stepwise approach provides an opportunity for the team members to voice their concerns and recommend revisions. Sensitivity to the surgical team members’ viewpoints will help engage them in the overall process, promoting empowerment and successful implementation.
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Implementing a safe surgery checklist does not require a lengthy trial period but rather an approach such as the PDSA Cycle. More time will likely be allocated to integrating checklist phases and elements into the electronic health record, providing educational support to quality improvement department personnel regarding outcome measures, and educating accounts receivable department personnel regarding CMS-required codes for billing and reimbursement. After the initial surgery team implements and refines the safe surgery program, these team members should act as role models to help train the remaining surgical staff members until the safe surgery checklist has been fully implemented in each OR. Lewin’s last step in the change model, refreeze, is to anchor the changes into the culture.22(p36) The change agent should identify what supports the change and any barriers to sustaining change. Leaders should continue to support the staff by being visible and using an established feedback system to listen to staff member concerns, facilitate interdisciplinary communication, actively resolve conflict, make adjustments, and empower team members. AORN Journal j 663
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During the implementation process, managers should use strategies that help prevent errors and adverse events, such as determining that staffing is adequate, personnel are not fatigued from working overtime, and staff members do not lack education and experience. As suggested in the literature review, staff mix should also be considered, especially when hiring and staffing the OR.9,10 In addition, scheduling staff members who are familiar with one another may positively affect team function.9 Familiarity contributes to anticipating the needs of team members and increases the overall strength and unity of the team.9 The DNP nurse should monitor for team cohesiveness, compliance, and awareness.
Quality Monitoring The last hinge of the three-hinge program is the evaluation of the overall effectiveness of the change process and interventions. A program’s success is most often determined by continuous quality improvement monitoring, benchmarking, and reporting. Quality reporting measure indicators should align with the CMS reporting measures.15 Reporting includes accounting for the number of patient burns, falls, wrong-site/ wrong-side/wrong-patient/wrong-procedure/wrong-implant surgeries, hospital transfer/admissions, prophylactic IV antibiotic timing, and safe surgery checklist use, as well as the additional important measures of patient injuries, infections, deaths, and near misses. Monitoring of these measures is a daily continuous process with reporting quarterly or as needed. The main goal of a quality improvement initiative is to identify trends and develop and implement prevention processes that reduce the risk of similar errors occurring in the future. A culture of tolerance and nonretribution should be created so that surgical staff members do not fear reporting incidents or near misses and all team members can learn from them. Leaders play a vital role in creating an atmosphere in which there is open dialog without punitive action.
CONCLUSION Surgical errors remain an ongoing significant problem in health care. Causative factors, the chief of which is human error, have been thoroughly explored, evaluated, and reported. Key surgery safety strategies include using time-out and safe surgery checklist procedures, decreasing OR interruptions, increasing RN staffing ratios, providing staff education, and encouraging reporting of near misses without fear of reprimand. The Safe Surgery Saves Lives program and the CMS ASCQR program have the potential to significantly reduce surgical error and improve patient care. Safe surgery programs and checklists can be easily adopted
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and adjusted to meet the needs of each specialty type surgery setting; however, special attention should be given to the change agent, surgical team cohesion, and continued quality monitoring for adherence. The three-hinge approach focuses on key players and components that may help guide health care providers to success, which is ultimately determined by patient outcomes.
References 1. Kohn LT, Corrigan JM, Donaldson MS; Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press; 1999. 2. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health Care System for the 21st Century. Washington, DC: The National Academies Press; 2001. 3. Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary M. Surgical never events in the United States. Surgery. 2013;153(4):465-472. 4. Patient safety primers: never events. (2014). Agency for Healthcare Research and Quality. http://psnet.ahrq.gov/primer.aspx?primer ID¼3. Accessed April 5, 2015. 5. Sentinel event data: event type by year 1995-2013. The Joint Commission. http://www.jointcommission.org/se_data_event_type_ by_year_/. Accessed April 5, 2015. 6. Human Factors Tool Kit. AORN, Inc. https://www.aorn.org/Secondary .aspx?id¼20893. Accessed April 17, 2015. 7. Fabri PJ, Zayas-Castro JL. Human error, not communication and systems, underlies surgical complications. Surgery. 2008;144(4):557-565. 8. Wiegmann DA, El Bardissi AW, Dearani JA, Daly RC, Sundt TM III. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;142(5):658-665. 9. Silen-Lipponen M, Tossavainen K, Turunen H, Smith A. Potential errors and their prevention in operating room teamwork as experienced by Finnish, British, and American nurses. Int J Nurs Pract. 2005;11(1):21-32. 10. Needleman J, Buerhaus PI, Steward M, Zelevinsky K, Mattke S. Nurse staffing in hospitals: is there a business case for quality? Health Aff (Millwood). 2006;25(1):204-211. 11. Shamliyan TA, Kane RL, Mueller C, Duval S, Wilt TJ. Cost savings associated with increased RN staffing in acute care hospitals: simulation exercise. Nurs Econ. 2009;27(5):302-331. 12. Lankshear A, Sheldon TA, Maynard A. Nurse staffing and healthcare outcomes: a systematic review of the international research evidence. ANS Adv Nurs Sci. 2005;28(2):163-174. 13. Murdock D. Trauma: when there’s no time to count. AORN J. 2008;87(2):322-328. 14. World Alliance for Patient Safety. Second Global Patient Safety Challenge: Safe Surgery Saves Lives. Geneva, Switzerland: WHO Press; 2008. http://whqlibdoc.who.int/hq/2008/WHO_IER_PSP_ 2008.07_eng.pdf?ua¼1. Accessed April 5, 2015. 15. ASC Quality Reporting. Centers for Medicare & Medicaid Services. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment -Instruments/ASC-Quality-Reporting/. Accessed April 17, 2015.
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June 2015, Volume 101, No. 6 16. Safe Surgery Checklist. July 24, 2012. The Joint Commission. http://www.jointcommission.org/safe_surgery_checklist/. Accessed April 11, 2015. 17. Nakhleh RE. Error reduction in surgical pathology. Arch Pathol Lab Med. 2006;130(5):630-632. 18. Reid J, Clarke J. Progressing safer surgery. J Periop Pract. 2009; 19(10):336-341. 19. Bennis W, Nanus B. Leaders: Strategies for Taking Charge. New York, NY: Harper & Row; 1985. 20. American Association of Colleges of Nursing. AACN Position Statement on the Practice Doctorate in Nursing. Washington, DC: AACN; 2004. http://www.aacn.nche.edu/publications/position/DNP positionstatement.pdf. Accessed April 17, 2015. 21. Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice. 2nd ed. Philadelphia, PA: Lippincott-Raven Publishers; 2011. 22. Lewin K. Frontiers in group dynamics: concept, method and reality in social science; social equilibria and social change. Hum Relat. 1947;1:5-41. 23. The PDSA Cycle. The W. Edwards Deming Institute. https://www .deming.org/theman/theories/pdsacycle. Accessed April 11, 2015.
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Resources Huber DL. Leadership and Nursing Care Management. 4th ed. Maryland Heights, MO: Saunders-Elsevier; 2010. O’Connor T, Papanikolaou V, Keogh I. Safe surgery, the human factors approach. Surgeon. 2010;8(2):93-95. Steelman VM, Graling PR, Perkhounkova Y. Priority patient safety issues identified by perioperative nurses. AORN J. 2013;97(4): 402-418. Ulanimo M, O’Leary-Kelley C, Connolly P. Nurses’ perceptions of causes of medication errors and barriers to reporting. J Nurs Care Qual. 2007;22(1):28-33.
Ronda Landers, DNP, RN is an assistant professor and online MSN program director at Cumberland University, Lebanon, TN, and an independent ambulatory surgery center consultant. Dr Landers has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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ABSTRACT Surgical errors can have serious consequences including patient deaths, and recent reports suggest that surgical errors continue to occur at unacceptable rates. Studies indicate that causative factors for surgical error include human factors, OR interruptions, staffing issues, and error-reporting trends. A “three-hinge” approach can be used to implement a safety program that emphasizes use of a safe surgery checklist and the Centers for Medicare & Medicaid Services reporting requirements for ambulatory surgery centers. The three hinges are the assignment of a change agent, ideally an RN with a doctorate in nursing practice; team cohesiveness; and continuous quality monitoring. AORN J 101 (June 2015) 657-665. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.04.013 Key words: surgical error, human error, patient safety, safe surgery checklist.
http://dx.doi.org/10.1016/j.aorn.2015.04.013 ª AORN, Inc, 2015
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o one person can ensure a patient’s safety during a surgical event. Rather, patient safety is the responsibility of a cohesive team of skillful and conscientious individuals. Safety considerations are integral to perioperative processes, yet the rate of surgical errors remains high. Factors that affect safety include team cohesiveness, the team’s ability to adapt to change, and sustained adherence to quality improvement measures. This article highlights the problem of surgical errors, presents a brief overview of causative factors, identifies evidence-based best practice interventions, and introduces a “three-hinge” surgical safety program implementation and evaluation model that may help guide surgical teams in making successful changes. Key facets of the safety program are an emphasis on use of a safe surgery checklist and the Centers for Medicare & Medicaid Services (CMS) reporting requirements for ambulatory surgery centers (ASCs).
PROBLEM AND SIGNIFICANCE Two landmark reports published by the Institute of Medicine in 1999 and 2001 provided health care professionals with a wake-up call to increase care quality and safety and reduce costs.1,2 The reports, To Err Is Human: Building a Safer Health System1 and Crossing the Quality Chasm: A New Health Care System for the 21st Century,2 detail health care-related errors and estimate that between 44,000 and 98,000 patients die each year as a result of these errors, many of which are surgery related.1 Although these reports created an increased awareness that has led health care providers to implement various improvements, more than a decade later, concerns remain regarding the number of surgical errors. In 2012, Mehtsun et al3 undertook a rigorous analysis of national malpractice claims and estimated that 80,000 “never events” occurred in US hospitals during the 20-year period between 1990 and 2010. Never events, or sentinel events, are medical errors that result in severe adverse consequences (ie, death or significant disability).4 Mehtsun et al3 retrieved data from the National Practitioner Data Bank, a federal repository of medical malpractice claims. They identified malpractice judgments and out-of-court settlements totaling $1.3 billion related to retained foreign bodies and wrongsite, wrong-procedure, and wrong-patient surgeries. As a result of these errors, 6.6% of patients died, 32.9% experienced permanent injury, and 59.2% experienced temporary injury.3 In 2013, The Joint Commission reviewed 102 incidents of unintended retention of foreign objects; 109 wrong-patient, wrong658 j AORN Journal
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site, wrong-procedure events; and 77 operative/postoperative complications.5 These statistics are alarming considering health care providers’ increased focus on patient safety and quality care during the past decade.
LITERATURE REVIEW Numerous research studies and health care literature reviews identify, establish, and verify factors that heighten the risk for surgical errors. Studies indicate that causative elements include human factors, OR interruptions, staffing issues, and errorreporting trends.
Human Factors “Human performance can be affected by many factors such as circadian rhythms, state of mind, physical health, attitude, emotions, propensity for certain common mistakes, errors and cognitive biases.”6(p21) Human factors in the OR can influence the occurrence of errors that include medication errors; procedural errors; errors involving the wrong site, procedure, or patient; foreign body retention (eg, gauze, sharps, instruments); and errors in execution (eg, inaccuracies in cutting, such as lack of precise direction, length, and depth control). Findings of a research study conducted by Fabri and ZayasCastro7 suggest that human error is the leading cause of surgical error. Their study assessed underlying medical errors that contributed to surgical complications. Medical error data were collected during a 12-month period from 9,830 surgical procedures. Findings showed an overall complication rate of 3.4% (n ¼ 332 patients), of which 78.3% were related to medical errors. Medical errors included
errors in surgical technique (63.5%), judgment errors (29.6%), inattention to detail (29.3%), and incomplete understanding of the problem or surgical situation (22.7%).
In 20% of procedures during which an error occurred, the error was considered to be a mistake (ie, the wrong thing was done), with a high correlation of the error having occurred during evaluation (ie, before the procedure). In 58% of the procedures, the researchers considered the error to be the result of the right thing being done incorrectly, with a high correlation of the error having occurred during execution. System and communication errors each accounted for 2% of errors.7 Fabri and Zayas-Castro found that the most frequent type of error was related to an “error in technique” and “was consistently reported as a slip occurring during execution.”7(p559)
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OR Interruptions Interruptions in the surgical flow can result in poor patient outcomes, near misses, and patient deaths. A 2007 study by Wiegmann et al8 categorized surgical flow disruptions into five categories teamwork/communication failures (ie, lack of team coordination, familiarity, and monitoring), extraneous interruptions, equipment and technology problems, issues of resource accessibility (ie, lack of needed surgical resources), and training-related distractions (ie, failure in management, guidance, or training of OR team members).8 The researchers found that the majority of errors caused by disruption were minor, and approximately 60% of surgical errors were noticed and rectified immediately by the surgical team; 32% of these were events that related to team members’ level of experience or the difficulty performing a specific technique or procedure. Team members did not detect approximately 40% of surgical errors immediately but did recognize and compensate for them at some point during the surgery. Teamwork and communication problems caused 52% of surgical flow disruptions. Rates for other types of disruptions were 17% external and extraneous disruptions, 12% supervisory and training distractions, 11% equipment and technology problems, and 8% resource inaccessibility.8
Staffing Issues Silen-Lipponen et al9 conducted a qualitative study that supported the relationship of teamwork and staffing inadequacies to surgical errors. They interviewed a convenience sample of nurses (N ¼ 30) who worked in surgical departments in three countries: Finland (n ¼ 10), the United States (n ¼ 10), and Britain (n ¼ 10). Data were collected from a larger international research project focused on the phenomena of nursing education and practice in different countries so that broad-range descriptions of OR teamwork could be ascertained. An important objective was to consider best practices for increasing patient safety in the OR. Findings identified potential sources of errors and approaches to error prevention. Findings related to the potential causes of errors concerned nurses’ need to manage multiple and simultaneous demands while at the same time providing safe, quality care. Factors the participants reported that could lead to error included the following: Fear of making an error because the possibility of harsh judgment and humiliation led to nervousness that could contribute to new errors.
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Frequent turnover in teams led to uncertainty in team members’ abilities, mistrust, and concern for patient safety. The threat of overtime work caused by overbooked surgery schedules resulted in pressure to work harder and more quickly. Continuous emotional distress caused by incidents such as arguments during surgeries, hostile behaviors, and the need for nurses to act as intermediaries between other professionals, weakened OR team cohesion. These types of distractions could potentially divert attention from the task at hand or the surgical procedure. Error prevention strategies provided by the respondents included that surgical teams in which members were familiar with each other were more likely to have confidence in each other’s skills and anticipate one another’s needs, creating a calmer atmosphere. Safety issues could be controlled by monitoring to detect and respond quickly to one’s own errors and errors committed by other members of the team and by willingness to provide instruction to others and perform safety checks when required. In addition, surgical scheduling that promoted the optimal order and timing of surgical procedures, continuous interaction and collaboration among members of the team, team member competency, and good management decisions, especially related to staff mix (eg, scheduling an adequate number of experienced staff members to ORs and shifts, considering team members’ levels of education), were factors the nurses believed promoted good teamwork and patient safety. Some research has suggested that having staff-mix ratios with greater numbers of RNs, especially baccalaureate-prepared RNs, may improve patient outcomes. Needleman et al10 suggested that a greater percentage of RNs might increase the quality of patient care, lower mortality rates, and result in overall cost reductions. They used data from 799 nonfederal acute care general hospitals in 11 states and regression analyses that found an association between nurse staffing and several nursesensitive patient outcomes to simulate the following three options to increase nurse staffing: 1. 2. 3.
raising the proportion of nursing hours provided by RNs to the 75th percentile for hospitals below this level, raising the number of licensed (ie, RN, LPN) nursing hours per day to the 75th percentile, and raising staffing to each of these levels in hospitals in which each was below the 75th percentile.
The percentile was based on the researchers’ judgment of the level of staffing feasible for most hospitals.10 Study results suggest that increasing the proportion of RN nursing hours without increasing the total number of nursing hours reduced net hospital costs. Increasing nursing hours, with or
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without increasing the proportion of RN hours, increased hospital costs up to 1.5%; however, an increase in RN hours reduced lengths of stay, adverse outcomes, and patient deaths. These findings suggest that employing a larger number of RNs might improve select nurse-sensitive outcomes and that the cost of employing these RNs could be offset by the reduced incidence of negative patient outcomes. A study by Shamliyan et al11 suggested that increased RN staffing in intensive care units and, to some extent, in surgical units is associated with lower hospital-related mortality and adverse patient events. In addition, a systematic review of international research by Lankshear et al12 showed evidence of a relationship between higher-skill-mix RN staffing and improved patient outcomes. All of these studies indicated a need for additional research specific to surgical staff mix and its relationship, if any, to preventing surgical errors. It would also be advantageous to investigate whether changes in surgical staff mix promote better team cohesiveness and performance.
Error-Reporting Trends Clinical staff members’ fear of reprimand and job loss influences error reporting. Nurses may fear disciplinary procedures because remedies after adverse events often have been focused on the individual and individual behaviors connected to the event.9 Too often, incident reports become specific to the individual who reported the error instead of what could be learned. Murdock13 discussed potential consequences resulting from surgical errors for the perioperative team: feelings of guilt, peer review hearings, licensure stipulations, and malpractice litigation. Malpractice cases related to retained foreign objects are very difficult to defend because of the doctrine of res ipsa loquitur (ie, the thing speaks for itself).13 Cases such as these are considered negligence.13 The main goal of quality improvement efforts should be to identify trends and develop and implement prevention processes to reduce the likelihood of similar errors occurring in the future. If error events are not reported because of fear, there is no opportunity to learn from these events.
EVIDENCE-BASED INTERVENTIONS Mitigating the causes of surgical errors requires implementing evidence-based safety interventions. In 2007, the World Alliance for Patient Safety, an initiative of the World Health Organization (WHO), launched the Second Global Patient Safety Challenge, “Safe Surgery Saves Lives,” to promote improved worldwide surgical care.14 A team of international experts identified four areas of focus for improvement
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surgical site infection prevention, safe anesthesia, safe surgical teams, and measurement of surgical services.14
A result of the safety challenge is the WHO Surgical Safety Checklist, which offers a three-phase surgical team task guide that targets these areas of emphasis. Using the checklist heightens the time-out procedure to a new level of safety by bringing together the members of the surgical team to improve the consistency of performing key safety checks before the induction of anesthesia, before the skin incision, and before the patient leaves the OR (Figure 1).13 In 2012, the CMS released new required reporting standards for ASCs with specific outcome measures to be reported electronically, including use of a safe surgery checklist congruent with the WHO checklist.15 Required reporting measures for the Ambulatory Surgical Center Quality Reporting (ASCQR) Program were included in the Calendar Year (CY) 2012 Outpatient Prospective Payment System ASC final rule.15 The CMS has set time frames for gradual implementation of the program’s eight outcomes (Table 1).15 Eventually, the same CMS guidelines and requirements will transition to all surgery settings, as has been proposed for hospital inpatient facilities for the fiscal year 2016 and beyond.16 One way to translate evidence-based practice (EBP) into clinical recommendations is to develop a safe surgery program with emphasis on using a safe surgery checklist and on the CMS ASCQR reporting requirements. When implementing a safety program, special consideration should be given to long-term adherence and consistency. Interestingly, the literature has focused on factors that influence surgical errors and on measures to counteract error occurrences; however, less emphasis has been placed on the factors that influence surgical teams to accept, implement, and continue to comply with the recommendations. Humans tend to become complacent or automated when performing the same task repetitively. It is well documented that humans perform best during unexpected or unanticipated events; when performing repetitive work, they are more prone to boredom and distraction and error is more likely to occur.17 This phenomenon is typified by the driver who arrives at a routine destination without recalling the details of the journey. The safe surgery checklist should not become another piece of paper for automated box checking, but rather should promote a systematic process that the surgical team performs in a conscientious interactive manner.18 Therefore, it is important to structure a safety program in a way that includes education about the need for change, team member support for change, and continuous monitoring for compliance with new processes.
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Figure 1. World Health Organization Surgical Safety Checklist. Reprinted with permission.
A THREE-HINGE APPROACH TO SAFETY PROGRAM IMPLEMENTATION The “door to success” has been referred to numerous times in various conceptualizations, but if considered in the contextual sense of change, the “door” can be a structural framework for change preparation and implementation. When one arrives at an entrance, little thought is given to the door and its design; most consideration is given to the desired passage. However, successfully opening the door depends heavily on the careful construction of the door itself. Deliberate attention to the three hinges then is imperative for successful operation. The implementation and evaluation of a safe surgery program can be likened to passage through a door in that the success of the program relies on the successful operation of three hinges: (1) a change agent, (2) team cohesiveness, and (3) quality monitoring (Figure 2).
Change Agent The middle hinge is the one most relied on to keep the door securely on the frame. In this approach, the middle hinge is the critical component of selecting the change agent who will most
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effectively set change in motion. Change agents have been described as transformative leaders who possess skills and innate characteristics that inspire people to change.19 The transformative leader as described by Bennis and Nanus19 is an individual who drives people to action and changes followers to leaders, who may then also become agents of change. The middle hinge of the model depicts a nurse with a doctorate in nursing practice (DNP) as an optimal choice for the leadership and oversight of the safety program. A major impetus for the DNP degree can be attributed to implementation of recent health care changes that are especially challenging for the nursing profession, such as advanced technology, new administrative constructs, and expanded professional roles. The primary focus of the American Association of Colleges of Nursing AACN Position Statement on the Practice Doctorate in Nursing is to improve the context within which care is delivered.20 This document states that nurses prepared at the doctoral level with a combination of clinical, organizational, economic, and leadership skills are able to critique nursing research and other clinically scientific findings that significantly influence health care outcomes.20 Melnyk and Fineout-Overholt21 called for mentors with in-depth knowledge AORN Journal j 661
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Table 1. Centers Myth: for Medicare & Medicaid Services Quality of Care Measures Number
1
Measures for Calendar Year (CY) 2014 Payment Determination
Type of Measure
ASC-1
Patient burn
Outcome measure
ASC-2
Patient fall
Outcome measure
ASC-3
Wrong site, wrong side, wrong patient, wrong procedure, wrong implant
Outcome measure
ASC-4
Hospital transfer/admission
Outcome measure
ASC-5
Prophylactic IV antibiotic timing
Process-of-care measure
Measures for CY 2015 Payment Determination ASC-6
Safe surgery checklist use
Web-based measure
ASC-7
ASC facility volume data on selected ASC surgical procedures
Web-based measure
ASC-8
Influenza vaccination coverage among health care workers
Internet-based surveillance managed by the CDC
ASC-9
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average-risk patients
Web-based measure
ASC-10
Endoscopy/polyp surveillance: colonoscopy interval for patients with a history of adenomatous polyps; avoidance of inappropriate use
Web-based measure
ASC-11
Cataracts: improvement in patient’s visual function within 90 days after cataract surgery
Web-based measurea
Measures for CY 2016 Payment Determination
ASC ¼ ambulatory surgery center. a Data submission deadline and payments affected are to be determined. 1. ASC Quality Reporting. Centers for Medicare & Medicaid Services. http://ascrs.org/sites/default/files/ASC%20Specs%20Manual_v3_0c.pdf. Accessed April 28, 2015.
of EBP and organizational change to foster the conscientious use of current best evidence in making decisions about patient care. The nurse with a DNP is trained to consider research along with clinical expertise and patient preferences to make decisions in the clinical setting and help overcome barriers. The DNP is thoroughly prepared, uniquely positioned, and well suited to translate current research and best evidence into the practice setting to enhance health care outcomes. Implementing a safe surgery program that includes a safe surgery checklist and emphasis on the CMS ASCQR program elements requires buy-in from primary stakeholders, including the medical director, chief nursing officer, managers or team leaders, quality improvement director, and members of the surgical team. As the change agent, the DNP nurse will need to gain stakeholder acceptance, approval, and support for best outcomes. Understanding change theory helps the DNP nurse prepare for change implementation and anticipate issues that might arise. Numerous change models offer steps to successfully implement change. Lewin’s change model22 describes change in three phases: unfreeze, change, and refreeze. The first step of change, unfreezing, is the most difficult in the change process because it involves altering 662 j AORN Journal
the status quo. The essential objective is to motivate reaction by delivering a compelling message. Emphasis should be given to facilitating communication within the team, listening to team members’ concerns, and being available to respond quickly to their questions or comments. Reid and Clarke18 provide helpful “myth busters” or answers to questions that staff members are likely to ask related to the safe surgery checklist. For example, Myth: The checklist won’t make a difference, we’re already careful and we have never had a problem. It will just create additional work. Bust: It’s true that the majority of the checks integral to the checklist are already routinely practiced . . . but they are not practiced systematically, consistently and with all essential personnel participating. If they were, a large number of incidents would not have happened. Health care staffs are human beings and human beings make mistakes, regardless of their level of competence, experience and usual vigilance.18(p339)
Team Cohesiveness The leadership provided by the change agent is a key element for building team cohesiveness, another hinge of the three-
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Selection of the initial team should be based on those who are eager to attempt change and are committed to improving workflow.18 The optimal team will have effective communication skills, interdisciplinary collaboration, and the ability to coordinate and prioritize, and team members should be individually experienced in the surgical procedures they are performing.8,9 Most important, the selected team members should exhibit confidence in one another’s skills. Overall, the team members should be familiar with each other and function well together.8,9 Patient safety improvements do not require the same scientific rigor that is seen in research.18 For a quality implementation initiative, Reid and Clarke18 recommend using a model that offers basic methodologies rather than methods used in randomized controlled trialsdfor example, the Plan, Do, Study, and Act (PDSA) Cycle.23 The PDSA Cycle is congruent with Lewin’s phases of change and provides steps for initiating change and continual improvement.23 Planda team identifies a goal for the purpose of change (ie, implementing a safe surgery checklist). Dodthe team implements the elements of the plan (eg, developing or adopting and implementing the safe surgery checklist). Studydthe team monitors outcomes to test the validity of the plan (eg, monitoring and evaluating use of the safe surgery checklist and its functionality); this step is key for assessing success or identifying problems and areas for improvement. Actdthe team integrates the learning achieved in the entire process; this step can also be used for adjusting the goal. Figure 2. The three-hinge approach to safe surgery program implementation. hinge approach. The leader should promote a working culture that cultivates empowerment, communication, and respect among team members. Identifying key players within the surgical staff who are highly skilled and motivated will help launch change initiatives. For example, perioperative nurses may greatly influence the success of using a safe surgery checklist because they are active participants in the surgical time out and most often initiate the process. The safe surgery program and checklist should be implemented with one surgical team on defined days and an integration period allowed until a smooth workflow is achieved. This stepwise approach provides an opportunity for the team members to voice their concerns and recommend revisions. Sensitivity to the surgical team members’ viewpoints will help engage them in the overall process, promoting empowerment and successful implementation.
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Implementing a safe surgery checklist does not require a lengthy trial period but rather an approach such as the PDSA Cycle. More time will likely be allocated to integrating checklist phases and elements into the electronic health record, providing educational support to quality improvement department personnel regarding outcome measures, and educating accounts receivable department personnel regarding CMS-required codes for billing and reimbursement. After the initial surgery team implements and refines the safe surgery program, these team members should act as role models to help train the remaining surgical staff members until the safe surgery checklist has been fully implemented in each OR. Lewin’s last step in the change model, refreeze, is to anchor the changes into the culture.22(p36) The change agent should identify what supports the change and any barriers to sustaining change. Leaders should continue to support the staff by being visible and using an established feedback system to listen to staff member concerns, facilitate interdisciplinary communication, actively resolve conflict, make adjustments, and empower team members. AORN Journal j 663
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During the implementation process, managers should use strategies that help prevent errors and adverse events, such as determining that staffing is adequate, personnel are not fatigued from working overtime, and staff members do not lack education and experience. As suggested in the literature review, staff mix should also be considered, especially when hiring and staffing the OR.9,10 In addition, scheduling staff members who are familiar with one another may positively affect team function.9 Familiarity contributes to anticipating the needs of team members and increases the overall strength and unity of the team.9 The DNP nurse should monitor for team cohesiveness, compliance, and awareness.
Quality Monitoring The last hinge of the three-hinge program is the evaluation of the overall effectiveness of the change process and interventions. A program’s success is most often determined by continuous quality improvement monitoring, benchmarking, and reporting. Quality reporting measure indicators should align with the CMS reporting measures.15 Reporting includes accounting for the number of patient burns, falls, wrong-site/ wrong-side/wrong-patient/wrong-procedure/wrong-implant surgeries, hospital transfer/admissions, prophylactic IV antibiotic timing, and safe surgery checklist use, as well as the additional important measures of patient injuries, infections, deaths, and near misses. Monitoring of these measures is a daily continuous process with reporting quarterly or as needed. The main goal of a quality improvement initiative is to identify trends and develop and implement prevention processes that reduce the risk of similar errors occurring in the future. A culture of tolerance and nonretribution should be created so that surgical staff members do not fear reporting incidents or near misses and all team members can learn from them. Leaders play a vital role in creating an atmosphere in which there is open dialog without punitive action.
CONCLUSION Surgical errors remain an ongoing significant problem in health care. Causative factors, the chief of which is human error, have been thoroughly explored, evaluated, and reported. Key surgery safety strategies include using time-out and safe surgery checklist procedures, decreasing OR interruptions, increasing RN staffing ratios, providing staff education, and encouraging reporting of near misses without fear of reprimand. The Safe Surgery Saves Lives program and the CMS ASCQR program have the potential to significantly reduce surgical error and improve patient care. Safe surgery programs and checklists can be easily adopted
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and adjusted to meet the needs of each specialty type surgery setting; however, special attention should be given to the change agent, surgical team cohesion, and continued quality monitoring for adherence. The three-hinge approach focuses on key players and components that may help guide health care providers to success, which is ultimately determined by patient outcomes.
References 1. Kohn LT, Corrigan JM, Donaldson MS; Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press; 1999. 2. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health Care System for the 21st Century. Washington, DC: The National Academies Press; 2001. 3. Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary M. Surgical never events in the United States. Surgery. 2013;153(4):465-472. 4. Patient safety primers: never events. (2014). Agency for Healthcare Research and Quality. http://psnet.ahrq.gov/primer.aspx?primer ID¼3. Accessed April 5, 2015. 5. Sentinel event data: event type by year 1995-2013. The Joint Commission. http://www.jointcommission.org/se_data_event_type_ by_year_/. Accessed April 5, 2015. 6. Human Factors Tool Kit. AORN, Inc. https://www.aorn.org/Secondary .aspx?id¼20893. Accessed April 17, 2015. 7. Fabri PJ, Zayas-Castro JL. Human error, not communication and systems, underlies surgical complications. Surgery. 2008;144(4):557-565. 8. Wiegmann DA, El Bardissi AW, Dearani JA, Daly RC, Sundt TM III. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;142(5):658-665. 9. Silen-Lipponen M, Tossavainen K, Turunen H, Smith A. Potential errors and their prevention in operating room teamwork as experienced by Finnish, British, and American nurses. Int J Nurs Pract. 2005;11(1):21-32. 10. Needleman J, Buerhaus PI, Steward M, Zelevinsky K, Mattke S. Nurse staffing in hospitals: is there a business case for quality? Health Aff (Millwood). 2006;25(1):204-211. 11. Shamliyan TA, Kane RL, Mueller C, Duval S, Wilt TJ. Cost savings associated with increased RN staffing in acute care hospitals: simulation exercise. Nurs Econ. 2009;27(5):302-331. 12. Lankshear A, Sheldon TA, Maynard A. Nurse staffing and healthcare outcomes: a systematic review of the international research evidence. ANS Adv Nurs Sci. 2005;28(2):163-174. 13. Murdock D. Trauma: when there’s no time to count. AORN J. 2008;87(2):322-328. 14. World Alliance for Patient Safety. Second Global Patient Safety Challenge: Safe Surgery Saves Lives. Geneva, Switzerland: WHO Press; 2008. http://whqlibdoc.who.int/hq/2008/WHO_IER_PSP_ 2008.07_eng.pdf?ua¼1. Accessed April 5, 2015. 15. ASC Quality Reporting. Centers for Medicare & Medicaid Services. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment -Instruments/ASC-Quality-Reporting/. Accessed April 17, 2015.
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June 2015, Volume 101, No. 6 16. Safe Surgery Checklist. July 24, 2012. The Joint Commission. http://www.jointcommission.org/safe_surgery_checklist/. Accessed April 11, 2015. 17. Nakhleh RE. Error reduction in surgical pathology. Arch Pathol Lab Med. 2006;130(5):630-632. 18. Reid J, Clarke J. Progressing safer surgery. J Periop Pract. 2009; 19(10):336-341. 19. Bennis W, Nanus B. Leaders: Strategies for Taking Charge. New York, NY: Harper & Row; 1985. 20. American Association of Colleges of Nursing. AACN Position Statement on the Practice Doctorate in Nursing. Washington, DC: AACN; 2004. http://www.aacn.nche.edu/publications/position/DNP positionstatement.pdf. Accessed April 17, 2015. 21. Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice. 2nd ed. Philadelphia, PA: Lippincott-Raven Publishers; 2011. 22. Lewin K. Frontiers in group dynamics: concept, method and reality in social science; social equilibria and social change. Hum Relat. 1947;1:5-41. 23. The PDSA Cycle. The W. Edwards Deming Institute. https://www .deming.org/theman/theories/pdsacycle. Accessed April 11, 2015.
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Resources Huber DL. Leadership and Nursing Care Management. 4th ed. Maryland Heights, MO: Saunders-Elsevier; 2010. O’Connor T, Papanikolaou V, Keogh I. Safe surgery, the human factors approach. Surgeon. 2010;8(2):93-95. Steelman VM, Graling PR, Perkhounkova Y. Priority patient safety issues identified by perioperative nurses. AORN J. 2013;97(4): 402-418. Ulanimo M, O’Leary-Kelley C, Connolly P. Nurses’ perceptions of causes of medication errors and barriers to reporting. J Nurs Care Qual. 2007;22(1):28-33.
Ronda Landers, DNP, RN is an assistant professor and online MSN program director at Cumberland University, Lebanon, TN, and an independent ambulatory surgery center consultant. Dr Landers has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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