FY25 Periop Safety in the OR - Licensed

FY 25 Safety in the or

Licensed Staff

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MedicationAdministration

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Objectives

Demonstrate proper communication when passing medication to sterile field and surgeon

Validate the five rights of medication adminstration

Demonstrate how to safely deliver medications to the sterile field

Discuss how to return unused medications

Discuss length of time of preparing medication prior to surgery and length of time on sterile field

Medication Safety

Validate the five rights of medication administration to minimize medication errors

Right Patient

Right Medication

Right Dose

Right Route

Right Time

Sterile technique is used to transfer medications and solutions to the field (using a syringe or sterile bag decanter, to avoid moving over a sterile field)

Medication Name, Strength/Dosage, Expiration Date, and Patient Allergies are read aloud by the licensed circulator and confirmed visually by the scrub person: this is always a two-person verification for each medication

"POPPING THE TOP" IS NOT A CORRECT METHOD OF TRANSFER

Medications & Solutions

Containers and syringes on the sterile field must be labeled with medication name and concentration immediately after a medication or solution is received All medications and solutions are labeled, even if there is only one on the field and even if it is just normal saline

Medications and solutions: Should not be placed on the sterile field more than 1 hour prior to the start of a procedureMedication administration should begin within 4 hours of medication being placed on the sterile fieldMedications used during the procedure expire after 24 hours

Medications & Solutions

When surgeon requests a medication or solution be passed to them during a procedure, they must: Verbally confirm the medication name and strength/concentrationVerbally confirm the patient’s allergies When presenting medication to sterile field, the licensed circulator must:Verbally state the name of the medication or solution and strength/concentrationVerbally state the patient’s allergiesThe surgical technologist must: Verbally state the name of the medication or solution and strength/concentration Verbally state the patient’s allergiesAt any handover, the relief person (licensed circulator or surgical technologist) must:Verify the labels of medications, solutions, reagents, or other chemicals Verify the patient’s allergies All of these must occur, even when only one medication is on the sterile field

Return of unused Medication

Unopened Packages:

Medications that are unopened in their original packaging are returned to the Automated Dispensing System (ADS). For controlled substances, the tamper seal must be intact. The staff member returning a medication is responsible for returning the medication to the correct pocket, as guided by the system. The package bar code is required to be scanned when returning to the cabinet.Two licensed staff witness and document the return of controlled substances. Medications that have entered an isolation room cannot be returned and are wasted.

Opened Packages:

Items that are opened, altered, or partially used cannot be returned and are wasted. Two licensed staff witness and document the waste of controlled substances.

Surgical Counts

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Objectives

Understand the importance of surgical counts.

Describe why accurate surgical counts are critical for patient safety and surgical outcomes.

Develop skills for effective communication and teamwork between all members of the surgical team to ensure thorough and accurate counts.

Explain the steps to take when counts are noted to be incorrect and the cascade for communication.

Explain the standard procedures and protocols used for counting surgical instruments, sponges, sharps, and miscellaneous items.

Out of the 88 events of unintentionally retained foreign items reported to The Joint Comission,

• 40% of the reported incidences resulted in severe patient harm,
• 35% required additional care or extended hospital stays,
• 16% were characterized as “other/no harm"

Did you know...

fACTS AND fIGURES

Surgical Counts

The Joint Comission estimates that only about 2% of these sentinel events are self-reported due to a variety of reasons, including fear of lawsuits , etc.

Source: https://www.aorn.org/outpatient-surgery/article/the-high-cost-of-retained-surgical-items

sURGICAL cOUNTS

1. Sponges
2. Sharps
3. Miscellaneous items small enough to be retained
4. Instruments,

• When a cavity is entered (thoracic cavity, pelvic cavity, abdominal cavity, retroperitoneal space, and mediastinal space)
• When wound size is large enough to retain an instrument
• When a cavity is entered through minimally invasive ports but there is a possibility to convert to open

Items to be counted Include:

The Counting Process

Note: There are a few exceptions to the instrument count:

• Wound size is too small to retain an instrument
• A closing and final instrument count does not have to be completed for laparoscopic cases in which a baseline instrument count is done prior to surgery start, and the surgery does not convert to open and remains laparoscopic.
• Instrument counts may be waived for surgical invasive procedures in which accurate instrument counts may not be achievable or practical, including:
• Complex procedures involving large numbers of instruments (e.g., anterior-posterior spinal procedures); and
• Trauma procedures.
• Note: When instrument counts are waived, unless the patient’s safety is at risk, intraoperative imaging will be performed before the skin closure.
• Continuous fluoroscopy and/or radiographic films are used prior to closure.
• Images are reviewed and approved by the attending surgeon/proceduralist prior to closure of fascia.

Are there exceptions to the instrument count? Click the light bulb icon to find out!

Test Your Knowledge

If the case you are preparing to do meets the instrument count exception, do you still count softs, sharps, and miscellaneous items?

It is per surgeon request!

No!

Yes!

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• The binding strip of packaged sponges must be broken
• Each sponge should be separated to confirm the correct number of sponges
• Packages of multi-pack needles will have cover paper removed and individual needles counted with both scrub person and circulator

The counting Process

Surgical Counts

Counting sponges and sharps

• Begin at the surgical site and immediate surrounding area
• Proceed to the mayo stand
• Proceed to back table, and lastly
• Complete counting sequence with items off the sterile field

What sequence should counts be performed?

1. Initial Count: Before an incision is made to establish a baseline. The Initial Count should be completed before the patient enters the OR, when possible.2. Additional counts are required:a. When new countable items, including instruments if applicable, are added to the field (As they are added, they are visualized and verbalized by both scrub personnel and licensed circulator); b. At the time of permanent relief of the scrub person or licensed circulator, even if direct visualization is not possible; c. When any surgical team member requests a count; d. Before closure of a cavity within a cavity (Cavity Count, e.g., uterus). 3. Closing Count: When wound closure begins. 4. Final Count: At the beginning of skin closure or at the end of the procedure if no skin closure occurs. 5. Reconcile Count: After the incision is closed.

When to perform counts

Surgical Counts

Click here to see the steps to take for a miscount

Who Performs Surgical Counts

• Licensed circulator and scrub person count together and out loud, visualizing each item.

During a count, if there is a discrepency, what steps should the team take? Click below to see the steps!

• Cannot be considered complete until those instruments used in closing the wound (e.g., malleable retractors, needle holders, scissors, towel clips) are accounted for after wound closure.
• These instruments must be removed from the wound/immediate surrounding area and be counted by the scrub person and the circulator for a reconcile count.

Final instrument count

Surgical Counts

Reconcile Count

• Circulator must mark the instrument count sheet to ensure that they can request each instrument used in closing during reconcile count.
• Procedure is as follows:
• First wound closure count
• Skin closure count
• Reconcile count

• The X-ray must include the entire operative site.
• After the X-ray is done, the licensed circulator calls the:
• (615-322-5033 before 5pm and 615-936-7723 after 5pm) for a STAT read by the most senior radiologist on duty (resident or faculty). They are in VUH 1406.
• Senior radiologist communicates on the call directly with the attending surgeon.
• The conversation is documented by the senior radiologist in a dictated reading of the film.
• Circulator will document:
• Accession number
• Radiologic findings
• Name of the reading radiologist
• For off campus locations, where an attending radiologist is not available, the attending surgeon/proceduralist will review the X-ray.

Considerations for X-rays

When one or more of the following risk factors are present:

• Case is a Level 1 trauma (and the wound is closed)
• Case had an unexpected change in procedure
• There is more than one specialty team and/or service lines performing unrelated procedures simultaneously
• Patient has a BMI of 40 or greater (50 or greater for Caesarian sections)
• When any member of the surgical team expresses any level of concern for a potential retained surgical item

Additional reasons to X-ray

RSI Risk Factors

Anatomy of The Count Sheets

Click Below

• 1st Cnt: your initial baseline count of instruments.
• 2nd Cnt: either your cavity closure or wound closure count of instruments.

• 3rd Cnt: Final Instrument count.
• Crit. Item: items that are needed from that pan. They are essential to have to do the surgery.
• Actual Qty: How many instruments you have in the pan.
• Required Qty: How many instruments come in the standard set for that pan.

Anatomy of the Instrument Count Sheet

iNSTRUMENT cOUNT sHEETS

Click here

Where do I chart the reconcile count?

Instruments used in closing the wound must be marked on the count sheet to reconcile once the wound is closed. You can use a circle, or a star, to mark the instruments you need back.

X-ray is not required for needles smaller than 10 mm

MICROSuture

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F. If the count remains unresolved, order a portable X-ray

E. If the sponge is found, recount to ensure correct count

D. Open all bagged sponges and recount

C. Inform surgeon & call your CSL

B. Search trash, linen, and floor

A. Recount item

place the items in theircorrect order

kNOWLEDGE cHECK

Check

sURGICAL cOUNTS

Pressure InjuryPrevention

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Objectives

Be able to demonstrate correct use of transfer devices

Be able to anticipate, obtain, and verify appropriate positioning and pressure redistribution equipment prior to procedure

During hand-off, staff should demonstrate communication including the results of skin and pressure injury assessments and interventions used to reduce the patient's risk of pressure injuries

Be able to appropriately use positioning equipment to prevent Pressure injuries

Perioperative staff are able to identify the intrinsic and extrinsic risk factors for pressure injury development

Know when to repostion the patient (whenever prodecure table is repositioned)

Be able to describe physiologic mechanisms that cause pressure injury

Identify bony prominences over which pressure injuries often occur

• A pressure injury (PI) is an injury which causes occlusion of blood flow, and can affect the skin, soft tissue, muscle and bone. It leads to the development of localized ischemia, tissue inflammation, tissue anoxia and necrosis.
• Pressure injuries may be caused by pressure, shear or friction tissue forces, which can occur because of prolonged periods of immobility during an operation, or while the patient is being repositioned or transferred.
• Aside from the high cost of treatment, pressure injuries also have a great impact on patients’ lives

and on the provider’s ability to render appropriate care to patients.

What is a Pressure injury

Friction removes the top layer of the epidermis and can also create microscopic tears in the skin, making it more vulnerable to pressure and moisture.

Friction

Skin shear is the mechanical stressing of capillaries and deep tissues when the body tissues move while the skin remains stationary.

Shear

Pressure is generally believed to be the most important of the extrinsic factors. The risk from pressure for a surgical patient is usually due to compression located at the site of a bony prominence.

Pressure

What causes a Pressure injury

• The back of the head and ears
• Shoulders
• Elbows
• Lower back
• Sacrum
• Ishial tuberosity
• Hips (greater trochanter)
• Inner Knees
• Legs
• Heels

Common Bony Prominences where Pressure injuries occur

• Perioperative patients are at increases risk for developing pressure injuries because of their immobility and lack of sensation during procedures.

• If a patient is assessed to be at high-risk for pressure ulcer development, a support surface with pressure redistributing properties greater than the traditional* procedure bed mattress should be used during the procedure.

• Perioperative pressure injuries may not be visually detected during skin assessments in the immediate postoperative period (from several hours to 3-5 days postop).

• The most effective preventative measures include risk assessment and pressure relief.

• Darkly pigmented skin should be assessed by checking the patient’s skin temperature and for the presence of edema, induration, and pain.

• Patients with a body mass index of ≥ 40 are at greater risk for nerve and pressure injuries.

• Using appropriate transfer devices can reduce shearing and friction forces when moving patients from stretcher to bed (and visa versa).

Did you know?

Instrisic vs Extrinsic Factors

PRessure Injury Prevention

• nutritional status
• fecal incontinence
• infection
• low hemoglobin level
• surgical risk related to type of procedure
• diastolic blood pressure <60 mmHg
• Poor skin turgor
• body mass index under 18
• age >60
• diabetes
• hypotensive episodes
• comorbidities
• hematocrit level <35
• female biological sex
• albumin level <3
• darker skin tones
• time spend immobilized before surgery

Intrinsic (things that we cannot control)

Extrinsic (things that can be controlled)

• pressure
• friction and shear forces
• moisture and heat
• unexpected prolonged procedure time
• time in the OR > 2 hours
• intraoperative external force
• intraoperative blood loss
• use of cardiopulmonary bypass
• surgical positioning
• use of anesthetic agents
• sedation
• vasopressor use
• type of surgery
• hypothermia
• type of surgical table mattress
• use of devices for position
• hypotension
• use of general anesthesia
• anticipated prolonged postoperative time

Stages of Pressure Injuries

Stage 1 - Pressure injuries are not open wounds. The skin appears reddened, may be painful, does not blanch, but has no breaks or tears.

Stage 3 - Pressure injuries extend throught the skin into deeper tissue and fat, but do not reach muscle, tendon, or bone.

Stage 4 - Pressure injuries extend to muscle, tendon, or bone.

Stage 2 - Pressure injuries ARE open wounds. The skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. It looks like an abrasion, blister, or shallow crater. In a dark-skinned person, the area may appear to be a different color than the surrounding skin.

Stage 1

Stage 2

Stage 3

Stage 4

Interventions that may reduce the risk of perioperative pressure injuries

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Have the appropriate number of people for lifting

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Apply prophylactic dressings liberally to protect bony prominences

Provide pressure redistributing support surfaces and padding

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Eliminating wrinkles in the sheets can prevent skin damage

Whenever procedure table is repositioned, patient position should be assessed

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Communicate with staff in the room about any positioning concerns

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Reposition when possible; may not entail full body movement (eg, micro-turn, micro-shift)

Elevate the heels off the bed, with slight knee flexion, and support the calves

High-Risk patients

*AORN states that cardiac, general, thoracic, orthopedic, and vascular procedures were reported to be the most common types of procedures associated with pressure ulcer formation.

Positioning Equipment to help prevent Pressure Injuries

• Table Mattresses
• Gel positioners
• Gel cushions
• Air-filled cushions
• Foam cushions
• Bed Extenders

• Alternating air mattresses
• Foam mattresses/overlay
• Gel-filled mattresses
• Water-filled mattresses
• Bead-filled mattresses
• Sheepskins

Pressure Redistribution Devices

Pressure Relieving Devices

The position of the patient during the procedure

Events during the intraoperative period that may have contributed to a position-related injury

Areas of the patient's body that should be assessed and monitored for potential injury

Procedure - specific risk factors (eg., hypotension, blood loss, hypothermia, time on the OR bed, surgical position

Standard information to provide to recovery room nurse

The type and location of implants, jewelry, or other items that cannot be removed

Specific actions taken to prevent patient injury

Chain of custody for any jewelry or items removed from the patient

Type and location of any additional padding

Type and location of safety restraints

Type and location of positioning equipment or devices

Patient position including any repositioning activities

Staff participating in the positioning

Preoperative Assessment

Documentation should include:

Postoperative assessment

In addition to chart documentation, pressure injuries that are discovered in the OR can be photographed with a Mobile Heartbeat phone that has the Haiku app. The Board Charge Nurse or your CSL has access to Mobile Heartbeat phones. ONLY Haiku should be used for photographing patients.

Policies and Sources

Policies and Sources

Policies and Sources

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Gauge vs. Size

Suture

Imperial Gauge refers to the diameter of the suture. The smaller the number, the bigger the diameter (e.g., a 1-0 is bigger than a 6-0). Note: Gauge is not the size. When our policy says X-rays are not required for needles 10mm or smaller, it refers to the size of the needle.

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Whenever a count is incorrect for a non-emergent case:

• Inform surgeon & call your CSL or Board Charge Nurse
• Your CSL or charge nurse will assist in searching and must be made aware of any incorrect counts
• Recount item
• Open all bagged sponges and recount (if the sponge count is incorrect)
• Search trash, linen, and floor

If the count remains unresolved, a portable X-ray must be done before the patient leaves the OR suite.

Steps to Take for incorrect Counts

Policy: Counts: Sharps, Sponges, and Instruments https://vanderbilt.policytech.com/dotNet/documents/?docid=19325&app=pt&source=browse

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Do you know...

Source: https://aornguidelines.org/guidelines/content?sectionid=173723395&view=book#245937431

• Use of a consistent, standardized practice has been shown to reduce the reports of incorrect counts and rates of overall serious reportable events that included RSIs.

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• Studies show cause for concern because of an increased risk for error when counts are recorded differently among providers.

Why Policy States to use a Standardized Count Sheet?

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