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Safety Program – Simulations and Mock Scenarios in Operating Rooms
Various forms of health care technology are being utilized today to enhance the skills of health care professionals, as well as improve quality outcomes. Considering the complex and high-risk nature of the operative setting, integrating simulations or mock scenarios has become a growing trend in fostering high-reliability interdisciplinary teamwork. The following paper focuses on the development and implementation of a simulation-based safety program within the operative setting of a health care facility in an effort to reduce adverse or never events. Although the safety risks related to implementing simulation and mock scenarios within the operative setting are identified, evidence is provided that suggests simulation of mock scenarios and tracking of long-term outcomes promotes the delivery of safe, quality care thereby reducing overall risks within the operative setting. Steps for creating the safety program are discussed.
Area of Interest and Safety Risks
The frequency, incidence and nature of adverse events within the operative setting appear to be increasing in recent years. According to Neily et al. (2009), approximately “five to ten incorrect surgical procedures occur every day in the United States” (p. 1028). While this figure may not seem considerable by some working within the health care field, one should ask themselves ‘What is an appropriate number for the occurrence of adverse events within an operative setting?’ and ‘How would you respond to a family member or friend who was involved in such an event?’
Not only have concerns been posed related to the occurrence of incorrect surgical procedures (e.g., wrong procedure, wrong site surgery and/or wro...
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...each interdisciplinary team member, as well as the health care facility’s ongoing prevalence of adverse or never events. The computer-based Likert response assessment tool would be designed to evaluate the interdisciplinary team’s perception of effectiveness for the simulation-based scenarios and debriefing sessions, while the facility’s quarterly figures related to adverse or never events would be compared to national figures (benchmarking).
Conclusion
Developing and implementing simulation-based scenarios is a growing trend within the health care field. Current evidence suggests use of this technology may help promote clinical and behavioral skills vital in standardizing point of care through an interdisciplinary approach. Ultimately, efforts toward implementing a simulation-based safety program may lend to improved quality outcomes within the operative setting.
Orlando Regional Healthcare, Education & Development. (2004). Patient Safety: Preventing Medical Errors. Retrieved on March 2014 from world wide web at http://www.orlandohealth.com/pdf%20folder/patient%20safety.pdf
The Institute of Medicine (IOM) reported in 1999 that between 44,000 and 98,000 people die each year in the United States due to a preventable medical error. A report written by the National Quality Forum (NQF) found that over a decade after the IOM report the prevalence of medical errors remains very high (2010). In fact a study done by the Hearst Corporation found that the number of deaths due to medical error and post surgical infections has increased since the IOM first highlighted the problem and recommended actions to reduce the number of events (Dyess, 2009).
Hospitals are busy places, and with so much going on it is hard to believe that mistakes are not made. However, there are some accidents that should never happen. Such events have been termed ‘never events’ because they are never supposed to happen. This term was first introduced by Ken Kizer, MD, in 2001 (US, 2012). The Joint Commission has classified never events as sentinel events and asks that hospitals report them. A sentinel event is defined as, “an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof” (US, 2012). Never events are termed sentinel events because in the past 12 years 71% of the events reported were fatal (US, 2012). Because these events are never supposed to happen, many insurance companies will not reimburse the hospitals when they occur. A study in 2006, showed that the average hospital could experience a case of wrong-site surgery, one example of a never event, only once every 5 to 10 years (US, 2012). This study illustrates how rare a never event is. Hospitals do not want these never events to happen any more than a patient does. To help prevent these errors, hospitals have created policies that, if followed, will minimize the possibility of a mistake. The consequences of never events are devastating and because of this the goal is to make sure that they are eradicated from hospitals and medical facilities.
The term “safety comes first” or more simply put, “safety first,” is a message that patients not only want to hear, but also want to know is the focus of the professionals that are caring for them; in particular, when they are under anesthesia and have limited or no ability to speak up or lookout for themselves. The National Patient Safety Agency (NPSA) has implemented two initiatives; Rocognising and Responding Appropriately to Early Signs of Deterioration in Hospitalised Patients (NPSA, 2007) and How to Guide: Five Steps to Safer Surgery (NPSA, 2010). Understanding that human beings make up the healthcare professional workforce, it is evident that tools and checklist can and will only be as good as the how people utilize and follow them. Thus, these initiatives “have been developed with consideration of human factors” (Beaumont & Russell, 2012). I know firsthand, that if my healthcare team would have followed these standards, I would have avoided torture, fear, and long term side effects from a routine hysterectomy procedure.
Surgical errors are seen in every hospital; however, hospitals are not required to report such incidents. Unintended retained foreign objects, often abbreviated as URFOs, are among those events that are often not reported.
Kimmel, K. C., & Sensmeier, J. (2002). A Technological Approach to Enhancing Patient Safety. Retrieved from https://blackboard.ohio.edu/bbcswebdav/pid-3906938-dt-content-rid-20290664_1/courses/NRSE_4510_1021_SEM_SPRG_2013-14/EHR_1%281%29.pdf
Wrong site, wrong procedure, and wrong patient errors are avoidable safety issues. Nearly 1.9 trillion dollars are spent on medical errors each year in the United States (Catalano & Fickenscher, 2008). Between 1995 and 2007, 691 wrong-site surgeries have been reported to The Joint Commission's Sentinel Event data repository (AHC Media LLC, 2008). In 2003 in response to the outcry for better patient safety The Joint Commission published their National Patient Safety Goals. Among the goals was the Universal Protocol. The Universal Protocol is actually drawn from several of the National Patient Safety Goals. It relies on multiple check points and the involvement of the entire surgical team to avoid such errors. Wrong site, wrong procedure, and wrong patient surgeries should never happen. The Universal Protocol is an evolving process which reflects the success and failures of healthcare practice, thus it requires periodic updates and policy revisions.
Safety is a primary concern in the health care environment, but there are still many preventable errors that occur. In fact, a study from ProPublica in 2013 found that between 210,000 and 440,000 patients each year suffer preventable harm in the hospital (Allen, 2013). Safety in the healthcare environment is not only keeping the patient safe, but also the employee. If a nurse does not follow procedure, they could bring harm to themselves, the patient, or both. Although it seems like such a simple topic with a simple solution, there are several components to what safety really entails. Health care professionals must always be cautious to prevent any mishaps to their patients, especially when using machines or lifting objects, as it has a higher
In health delivery system, one common goal for all providers, doctors and administrators is to provide high quality health care services at low costs. But in the United States, health care spending has increased drastically, but outcomes are not efficient. In the recent study conducted by common wealth fund shows that United States health care spending is 50 percent more when compared to 13 top nations in the world. [1] This report also shows that despite of having high health care expenditure in the United States, the health care outcomes are worse when compared to other countries whose health expenditure is low. To address these problems and improve outcomes, patient safety and satisfaction, in the field of surgery the American
Vital improvement for patient safety has triggered an enormous amount of positive change in the healthcare system. There were “1.6 million adverse events each year that led to 180,000 deaths” (Liang & Mackey, 2011). In a review, avoidable errors led to $19.5 billion dollars in healthcare expenses (Liang & Mackey, 2011). The National Patient Safety Agency analyzed 425 deaths from acute care hospitals and found “15% of the deaths were related to unrecognized patient deterioration” (Higgins, Maries-Tillot, Quinton, & Richmond, 2008). This finding led to the Institute for Health Care Improvement’s promotion for the use of an early warning scoring system to assist with identifying deteriorating patients (Albert & Huesman, 2011).
Before starting this course and before reading the first section of Wall of silence: The untold story of the medical mistakes that kill and injure millions of Americans, I did not have much awareness of medical errors. My awareness extends to hearing stories about medical utensils and supplies being left in patients after surgery or hearing stories of patient receiving the wrong dose of medication, but hearing stories about the extent of deaths related to medical errors left me astonished. I was in awe reading the amount of deaths reported each year related to medical errors, not including the errors that are not reported. This book brings about the awareness and importance of implementing strategies to decrease medical errors.
Retrieved from: Ashford University Library Boaden, R., & Joyce, P. (2006). Developing the electronic health record: What about patient safety? Health Services Management Research, 19 (2), 94-104. Retrieved from http://search.proquest.com/docview/236465771?accountid=32521.
The patient safety program in hospital setting is intended to reduce medical errors and hazardous conditions by assuring an environment that inspires error identification, reporting and prevention through education, system enhancement for any adverse occasions such that information about sentinel events that frequently occurs in health care are built in the system progressively for risk reduction. Through education component, proper and effective orientation and training that emphasizes clinical and non-clinical aspects of patient safety, including an inte...
Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency coordination task force with the help of government agencies. These government agencies are responsible for making health pol-icies regarding patient safety to which every HCO must follow (Schulman & Kim, 2000).
The PICOT model creates a template for clinicians that allow them to break down clinical questions related to a specific population. With this model, clinicians find information via online databases and journals to gather accurate data. Often, health care providers have the capacity and interest in formulating a question, however they lack research strategy (Riva, Malik, Burnie, Endicott & Busse, 2012). The PICOT model helps bridge the gap between questions and answers. A concern of mine in health care deals with mistakes made in the operating room. The proposed research question is “Does the implementation of the World Health Organization’s Surgical Safety Checklist, in its entirety, reduce the rate of surgical mistakes and increase positive results compared to surgeries that do not follow all aspects of the surgical safety checklist; especially in lower income countries or emergency surgery situations where time is not