Ebt Task1 Essay

In accordance with the World Health Organisation (WHO 2008) checklist and Local trust policies, a team briefing was held before the day’s list started. The checklist is part of a second Global Patient Safety Challenge initiative entitled ‘Safe Surgery Saves Lives’, aimed at reducing the number of surgical deaths worldwide and was launched in June 2008. This not

To do this we must first briefly consider the current role of the ODP in relation to the multi-professional team, within the operating department. ODP’s work alongside surgeons, anaesthetists and theatre nurses for the anaesthetic, surgical and recovery stages of an operation. Their duties include assisting with equipment and instruments and post-operative monitoring of patients using specialist equipment.

In 2003, as an outcome of all the sentinel events reported to the Joint commission lead to the creation of the “The Universal protocol for preventing wrong site, wrong procedures, and wrong person surgery” (Mulloy & Hughes 2008). So, one of the ways that could have potentially prevented the situation from happening at the first place was implementing the universal protocol procedure. According to the protocol the conduction of proper pre as well as post-operating procedures are extremely mandatory. Therefore, by enforcing a standardized routine pre-operating procedure such as verifying the patient as well as the correct site for the procedure, by having the medical staff or preferably the physician marking the operating site with his or her initials before the surgery will be an effective preventive measure (Mulloy & Hughes 2008).

Second, the nurse commences assessment with an evaluation of patient’s airway, breathing, and circulation for any signs of inadequate oxygenation and ventilation. One of the patients’ temperature was 102 F and the physician recommended pain medication (dilaudid) and it was administered instantly. The nurse gets vital signs and compare the result with intraoperative care. The nurse chart vital signs every 5 mins for the next 15mins, every 15mins for the next hour depending on the recovery state of the patient. I also noticed that for diabetic patients, the nurse checks for blood glucose and also compare result with intraoperative care unit result. Third, the nurse assess pain although the patients receive pain medication before surgery. Fourth, the nurse assess surgical site (dressings and drainage). Fifth, the nurse assess neurologic (level of consciousness, orientation, sensory & motor status, pupil size and reaction. Finally, the nurse assess gastrointestinal (nausea, vomiting, intake of

VASNHS Surgical Specialty Outpatient department has a designated pre-operative management unit that oversees the patients undergoing surgery. The predicaments stem from various guidelines or protocol originating from numerous surgeons and clinics. At present, the pre-operative nurses abide simple pre-op instructions (NPO protocol, medications, what to bring, during the surgery, transportation, cancellation instructions) for the entire Surgical Specialty Outpatient department. Surgical procedures are being canceled due to lack of communications and cancelations of patients prior to surgery date.

Lastly, in the surgery theatre, misidentification may happen due to the same factors formerly mention plus failure to mark site/side of surgery, failure to properly perform time-out, and multiple surgical teams (Chan et al., 2010). To analyze the risk for these errors, few factors will be analyzed including human factors (staffing, scheduling, supervision, and qualification), equipment and technology (scanners, computers, and software), Communication (between staff and patients, between staff, between staff and physician, between physician and patient, and between units), environmental factors (physical, safety, security, and preparedness), and procedures and policies (planning, staff education, patient education, protocols, patient identification, and patient observation) (Chan et al., 2010).

"The final count is correct" is a statement that operating room (OR) nurses use on a daily basis. Their belief in the count being correct does not change the facts. The incident of a retained surgical item (RSI) was the most frequently reported sentinel event from 2010 through 2012 and again in 2014 (The Joint Commission [TJC], 2012, 2014). Counting of surgical items is necessary to ensure maximum protection and safety of the patient. One of the most important aspects of the OR nurse 's job is the final count of items used in a surgical procedure. Risk factors for RSIs are greater with different situations and known barriers frequently lead to a more difficult count. The damage potential of a RSI can be as great as death of the patient.

They are very easy to navigate and it only took minutes to locate the information I needed for this project. The Joint Commission and the World Health Organization (WHO) set the standards and recommendations that hospitals follow when making their policy and procedures for patient safety and patient care. These two websites clearly state the required time-out elements and expectations of a surgical time-out. This information was very helpful in helping me make sure that all required elements were included.

At least half a million deaths per year could be prevented with effective implementation of systemic improvements in operating rooms. Specifically, multiple studies have found implementing the use of the WHO Surgical Safety Checklist would significantly reduce surgical morbidity and mortality due to surgical errors.

Your health care providers, including your surgical team, take many precautions to keep you safe during surgery. This sheet explains the steps that your health care providers take to prevent surgical error. It also lists some things you, your friends, and your family members can do to help reduce the risk of a surgical error.

After reviewing the case study, the liability falls with all parties involved with the patient’s care, not just the surgeon. In this situation it was a process problem. There was obviously a universal protocol process at the facility as the case study identified several safety check processes. Unfortunately, there were several breakdowns in the process. First, the person who marked the patient was not the consented surgeon who was performing the procedure. As the patient mentioned she never had the opportunity to speak with the person who mismarked the spot. Second, the patient was not involved in the site marking. The patient mentioned if she had the opportunity to use a mirror to verify the marking she would have noticed it was incorrect. Third, the patient remembered that a “time out” never actually happened in the procedure room. Finally, from the patient’s perspective, “there just seemed to be a lot of pressure on people to get it over with, get it done” (Thomas, 2009, p. 670). Some of the reasons that may have added to the risk of wrong site surgery were distraction factors and time pressures (Dillion, 2008).

Once everyone finishes interviewing the patient, the anesthesiologists bring the patient to the operating room. In the room, the nurse again confirms, if she has received the right patient by checking the patient 's identification band and by asking the patient. Before prepping the surgical site, the nurse, anesthesiologist, and the surgeon confirms the patient, the surgical site, and position of the patient. The nurse does the surgical "Time Out," once the patient is draped, and just before the incision. During time out, the nurse will loudly announces the elements of time out; correct patient, verifying the correct site and laterality, correct position, correct procedure, availability of correct implants or equipments, availability of pre-op radiographs, any prophylaxis antibiotics, and allergies.

A Wrong- site Surgery is defined as a Never Event where a surgery may be carried out on the wrong side of the body or on an incorrect body site. Events that involve surgery on the wrong body part, surgeries that involved incorrect procedure, or had a procedure intended for another patient are rightly termed Never Events. These "wrong-site, wrong-procedure, wrong-patient errors" (WSPEs) are errors that should never occur and indicate serious underlying safety problems.

Wrong site surgery remains the most frequently reported sentinel event, with 908 wrong site surgeries reported since 1995 (AORN, 2010). During the late 1990’s and early 2000’s there was a tremendous public concern and lack of trust for the medical profession, especially within surgical services. We as healthcare professionals needed to step up to the plate, slow down, and take responsibility to improve the quality of care we provide for our patients. Although there still is some resistance from surgeons and other healthcare professionals, overall there has been a general acceptance to universal protocol.

“The Process Improvement in Stanford Hospital’s Operating Room” case has many issues when it comes to regards to its existing instrument provisioning process taking place within the Operating Room (OR) of Stanford’s Hospital. This process entails getting instruments ready for a surgery in the OR and the cleansing of these instruments afterwards; however, there are many problems that arise in this process.