NL FY25 Periop Safety in the OR - Non-Licesned

FY 25 Safety in the or

Non-Licensed Staff

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MedicationAdministration

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Objectives

Demonstrate proper communication when passing medication to the sterile field and surgeon

Validate the five rights of medication adminstration

Demonstrate understanding of 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 the 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!

Question 1/1

• 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:
• (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

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.

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

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?