How to Read the Surgery Board at the Hospital

BMJ Open Qual. 2017; vi(2): e000021.

Electronic brandish board in operating theatres for piece of cake patient identification

Si Ching Lim

¹ Department of Geriatric Medicine, Changi General Hospital, Singapore,

Adrian Jit Hin Koh

² Department of General Surgery, Changi General Hospital, Singapore,

Edward Fly Hong Poon

^three Department of Geriatric Medicine, Ang Mo Kio - Thye Hua Kwan Hospital, Singapore,

Received 2017 Feb fourteen; Revised 2017 Jun 28; Accepted 2017 Jul 29.

Abstract

Objective To correct patient identification for surgery nd reduce gamble of incorrect site surgery.

Surgical care is loftier chance and complex and errors are associated with huge negative implications. The need to place patients correctly earlier surgeries is important to reduce risk of wrong-site surgeries. Operating theatres (OT) are a highly stressful work environment where time and resources are precious and errors are more probable to occur. Having a clear brandish of the two patients' identifiers improves ease and safe during fourth dimension out and noting critical results in the OT.

Methodology Deming's Plan-Do-Study-act cycle where the work group come across regularly to review results of various strategies put up and implement further changes.

Results Both the surgeons and nurses plant it safer to accept patients' ii identifiers and nature of operation on brandish while noting critical results and confirming patients' details during time out.

Keywords: wrong site surgery, two patient identifiers, electronic display lath, operating theatres, critical results notification

Introduction

Surgical care is complex for patients, where potentially devastating errors and near misses can occur. The failure to place patients in healthcare correctly results in medication errors, transfusion errors, discharging infants to incorrect families, testing errors and procedure errors. The UK National Patient Condom Agency reported 236 incidents and near misses related to wristbands, which were either missing or displaying wrong information.¹ The Joint Committee has listed right patient identification every bit its first First International Safety Goal introduced in 2003 and continues to be a requirement for accreditation.²

One of the objectives listed in the WHO safety surgery 2009³ involve making sure the surgery is performed on the correct patient, right procedure and on the right site. The occurrence of incorrect-site surgeries (WSS) (left/right side or wrong body parts), wrong patient and wrong surgery is termed never events, errors that should never occur and indicate serious underlying safety lapses. WSS causes devastating injuries to patients and has negative effects on the surgical team. Such errors occur in approximately ane in fifty 000–100 000 surgical procedures.⁴ Among some of the reasons listed for WSS include communication failure, non-compliance to safety procedures, emergency cases, multiple surgeons, multiple procedures, time pressure, unusual set-up, equipment and room changes.^5–7 With this information, the team embarked on the project to ensure safety of patients when they are in the OT.

In the local infirmary, the patient must exist identified using two identifiers, which include the patient'southward proper noun and identification carte du jour (IC) number. The IC number is unique to each and every Singaporean and Singapore permanent resident.

Routinely, patients planned for operation undergo several checks at various points en route to the operating theatre (OT). The checks are in the form of checklists, and the nurses involved in the checks are required to sign their names at every checkpoint. Patients' exact location is displayed on the OT dashboard by scanning the patients' wristband equally they make their journeying through the OT.

In the induction room, the surgeons verify the patient'southward proper noun, IC number, nature of operation and do site marking with the patient fully awake. Time out is a brief pause but before incision for the whole surgical team of nurses, surgeons and anaesthetist to ostend the patient's identification, the site and the correct functioning. The Joint Commission requires that all the team members are present during time out and exist actively involved in the process. The checklist used during time out is documented and filed.

The following were the challenges at fourth dimension out for our surgeons:

• lack of a clear brandish of the patient's name and IC number; the surgeons recall the patient's details from retentivity

• time-consuming and inconvenient to verify with patient's wrist tag for name and IC number, from under the sterile towels.

Critical results are often called through to the OT via phone and communicated to the medical or nursing staff. The lack of patient'southward name and IC number on clear display causes delay as the nursing staff needs to cheque with the patient's case notes in order to verify.

With this information, the squad embarked on the project to ensure safety of patients when they are in the OT.

Project aims

• improve ease of verification of the patient's identity, with two patient'southward identifiers during time out and acknowledgement of disquisitional results in the OT

• display of the nature of surgery and the patient's drug allergies for ease of verification

• reduce the future chance of wrong patient, site and surgery.

Methodology

The project was planned and carried out using Deming's Plan-Do-Written report-Act cycle.

A workgroup comprising surgeons, hospital'south information technology (It) team and the OT nursing staff was formed to explore various ways to put up a display of the patient's name and IC number. 10 meetings were held, and during the first coming together the members brainstormed and explored various ways to put up a display of the patient's name and IC number. The Ishikawa diagram was used to chart the problems and the challenges faced are listed beneath:

• the ideal location for putting upwardly the brandish (figure 1)

  • If the display lath is nigh the wall telephone, it is user-friendly for the receivers to note the two patient identifiers when calls come through.

  • However, the wall telephone where critical results are called through is a distance away from the operating table.

  • Visibility of data being displayed on the wall is poor from the operating table where the surgical squad works. This is an important factor to consider during fourth dimension out when the surgical team needs to actively check the patient's data.

  • Display board placed near the operating table is convenient for the surgical team for time out, just may not be clearly visible from the wall telephone when receiving critical results.

  

• visibility of display from both the wall phone and the operating table

• transcribing errors

• regular update of information on display after every changeover of patients.

  • The previous patient'south identifiers, nature of surgery and drug allergies are replaced with the current patient's details.

Before embarking on the project, the squad collected baseline information using a survey form on the demand to accept the patient'due south proper name and IC on display in the OT. More 70% of the general surgeons and OT nurses agreed that there is a need to accept their patient'south name and IC on display, and over lxxx% agreed that the aim for doing so is to improve patient prophylactic, peculiarly during fourth dimension out, and to check the correct site and correct functioning.

The side by side priority was to decide what patient details to brandish on the board to reduce the hazard of WSS and making sure the results being called through to the OT belong to the correct patient. The survey results showed 73% of surgeons and 64% of OT nurses would like to take the nature of performance on brandish to facilitate time out.

Strategy ane

The squad proposed to start with a conventional whiteboard nearly the wall telephone since it was inexpensive, durable and readily available. Drilling the OT walls is discouraged because the walls in OTs consist of sandwich layers of physical, air and lead in guild to maintain the positive pressure within the OT. Therefore, the squad created a makeshift whiteboard using a laminated slice of A3 newspaper, which was glued to the wall (effigy 1).

Nosotros evaluated the strategy and collected feedback from the nursing staff using a survey form. There were only 24% of nurses and 7% of the surgeons who preferred using the whiteboard as a ways for display. The other points related to the whiteboard are listed beneath:

• loftier risk of errors with transcribing

• the nurses did not want the responsibilities of updating the board afterwards every patient; in that location were occasions where the board was not updated, leaving the wrong patient'due south information on display

• legibility of handwriting

• visibility of handwritten words and numbers from the operating table where the surgeons work; this was author-dependent and inconsistent; the makeshift whiteboard is about 3 g from the operating table.

Strategy ii

The team then brainstormed and proposed using a PowerPoint display of patient's proper noun, IC number and nature of operation on one of the figurer screens, near the operating table. The details were manually keyed in by the surgical squad (figure 2).

Later on a month of airplane pilot, the squad sent out a survey form to collect feedback from the departments of general surgery and  ear nose and throat (ENT). The result of the survey showed that 72% of nurses and 50% of surgeons preferred an electronic means of displaying the patient's information, rather than handwritten form. The other points related to electronic display were the following:

• Visibility was not a major concern with PowerPoint display, from the operating table or the wall telephone.

• Fourth dimension-consuming and risk of errors while typing in the patient's details.

• Needs regular updating with every changeover of patient.

There was a squad of staff who did random survey for a total of 2 consecutive months in selected OTs to observe the frequency of surgeons putting up a display either on the makeshift whiteboard near the wall phone and/or PowerPoint display on the estimator screen near the operating table. They noted that in the first month of the airplane pilot, merely 54% of the surgeons bothered to have the patient'south proper name and IC number on display on either the whiteboard and/or PowerPoint on computer screen. The compliance rate improved to 64% at the 2nd month of pilot project. It was noted that the bulk of display was on both the computer screen and the whiteboard. Only one instance was displayed on whiteboard alone.

Strategy 3

The team then met and brainstormed to finally come up out with the possibility of an automated electronic display where the OT staffs will scan the bar lawmaking on the patient's wrist tag to pull up the required information for display. The usual patient'southward bar code registers the patient'south IC number when the bar code is scanned. The squad worked with the IT department to create a button on the hospital's electronic medical records, in the operating theatre management arrangement (OTMS), to flash out the patient's name, IC number, consultant-in-charge, nature of operation and the patient's drug allergy history to display on the electronic display lath.

Scanning the patient's bar code on the wrist tag is a routine procedure in a patient's journeying through OT, every bit shown in figure 3. The patient's whereabouts in the OT are displayed on a dashboard at various points in the OT and the OTMS on the electronic medical records and then the hospital personnel can rails the patient'southward movement in OT. At step 5, when the patient is transferred to the operating table fully awake before amazement, scanning the patient'south bar lawmaking will evidence the patient's details for display, as shown on figure iv.

Patient'south journey through the operating theatre (OT)

Automatic display of patient'south identifiers

At the cease of the surgery, the patient is not scanned out of OT. When the patient is transferred out of the OT to the recovery room, he/she will exist scanned in the recovery room (effigy 3), so an account is created in the OTMS and this is the only way in which nurses tin can enter the patient'south parameters into the system and this record cannot exist activated any other mode. Once the patient is in the recovery surface area and his/her location is confirmed, the display board in the OT goes blank. When the patient is gear up to be discharged from the OT to step-down intendance area, the recovery room is required to print out a discharge summary and close the whole journeying across the OT. In the issue that a new patient arrives in the OT before the previous patient is scanned in the recovery area, the new patient'south details will appear on the electronic display board.

In the outcome that the patient's wrist tag was non scanned when he/she was transferred onto the operating tabular array and details are not shown on the display board, time out volition be stopped until the patient is verified and scanned before time out tin can recommence and surgery can start.

Discussion

The aim of this project was to improve patient rubber during their journey through the OT, ensuring that patients are identified correctly, and to reduce chance of WSS. The employ of patient's ward and bed number as identifiers is discouraged since patients' wards and beds alter as intendance needs change. Misidentification of patients is identified as a root cause of many errors, and the Joint Commission listed right patient identification in 2003 as its outset international patient rubber goal and is a requirement for accreditation. There are currently various methods used in healthcare to assistance with correct patient identification. The classic is the wrist tag that patients wear, which has the disadvantages of existence dislodged, lost, wrong patient's details on the tags, wrist tags with missing or illegible information, and presence of more than one wristbands with conflicting information.^{1 8} Other technologies that have been tried in healthcare include radiofrequency tagging, which is expensive, and personal biometrics similar thumbprint, which is unique to each individual. Bar-coding is currently the best technology; it is inexpensive and readily available for labelling drugs and specimens.^ix For the study environment, the patients clothing a wrist tag with their individual name and IC number printed with a bar code. Some of the patients as well habiliment a radio tagging device allowing healthcare workers to rail their whereabouts in the hospital compound during their stay. Scanning the bar codes is also used for other purposes. During medication rounds to reduce medication errors, phlebotomists scan bar codes on patients' wrist tags to ensure specimen collected and request matches and OT scans bar codes to locate the patients circulating through the OT. Scanning the bar codes leads to the hospital'south medical records organisation. Using bar codes eliminates possible errors associated with misidentification, particularly when we have uncommunicative patients or patients who have cognitive impairment who are unaccompanied and unable to tell united states of america their name or IC numbers.

The risk of human errors, poor communication and lack of teamwork is present in all healthcare settings. Misidentification of patients and WSS occur due to lapses in human being performance, and to reduce errors improving the system where healthcare workers practise their work is more reliable than perfecting human performance.¹⁰ In this project, verification of patients' identifiers occurs when the patient is seen, when the surgery is scheduled, on admission to the ward, prior to any procedures that include phlebotomy, during patient transfer to another caregiver, at the induction room prior to site marker and prior to sedation, and at fourth dimension out earlier the surgery. Some of these checks involve scanning the bar codes on their wrist tags and verbal verification. The patients are also asked to verify the surgical procedures and site confronting the consent form which they are scheduled for. For patients who are uncommunicative or unconscious, verification of identifiers and surgery with a next of kin checking against the patient's wrist tag and consent form is required.

Preoperative verification using checklists allows discrepancies to surface. Reviewing the medical records and verification with the patients are useful steps to resolve these discrepancies.^xi Adoption of the Universal Protocol adheres to the three elements: patient identification, site marking and fourth dimension out. The Universal Protocol must be strictly adhered to, and any team members must speak up if they experience patient safety is compromised.¹² Time out serves as the final verification before the procedure and is an important footstep that allows the team of surgeons, nurses and anaesthetist to have a quick briefing, and has been shown to prevent WSS, with improvements in the communication on the right site and correct performance.¹³

Critical results from the laboratory and the radiology departments are often called through to the OTs as these results may influence the extent of surgery. Individual hospitals accept their gear up criteria to define critical results. Miscommunications of critical results may upshot in delayed treatment and result in serious harm. The Joint Commission requires that the hospital has a guideline on reporting and receipt of critical results, to whom and by whom disquisitional results are reported, and that compliance is monitored. The receiver should routinely practise a 'read back' to ensure that the results communicated are accurately received. In the OT and emergency situations, read back is often not possible. The information communicated must be documented.^fourteen In the OT setting, time is disquisitional. The results chosen through may affect the extent of surgery, or interventions for abnormal results can exist instituted as early as possible. In the OT, where the patient'southward identifiers are not conspicuously displayed, it is possible to miscommunicate the wrong patient's results, especially if patients' names sound similar and the staff receiving the aberrant results has to retrieve patients' identifiers from memory for verification. In healthcare setting, relying on homo memory is prone to errors, especially if there is inexperienced staff, pressure for time, inadequate checking and inadequate data. At an individual level, the human memory has a finite capacity that tin can be further afflicted by fatigue, slumber deprivation, stress, hunger and disease. In addition, language barriers may be another factor for miscommunication.¹⁵ In the report setting, the critical results are reported to the OT staff, and the date and time of advice are documented for hereafter verification. The staff may be asked to do a read back and the didactics is to cheque the electronic medical record system to view the actual written report, since documentation and read dorsum are frequently not viable.

Determination

Healthcare facilities are a high-risk environment for our patients. Human errors can cause serious threat to patient safety specially in highly stressful environment similar the OTs. Improving the organisation creates an actress layer of protection against human errors; for example, identifying the right patient for the right surgery reduces the adventure of WSS.

Footnotes

Contributors: The paper submitted is an original QI project and has non been published elsewhere. Information technology was exhibited at the last BMJ Healthcare Rubber and Quality Briefing in Singapore in September 2016.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5609351/

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