Operating Room Nurses Association of Canada

Implementation Guide

Surgical Safety Checklist

April 2010

Operating Room Nurses Association of Canada

Canadian Anesthesiologists’ Society

Royal College of Physicians and Surgeons of Canada

Adapted from

Canadian Patient Safety Institute Implementation Kit for the Surgical Safety Checklist

and

WHO Surgical Safety Checklist condensed How-to-Guide

Approved by the WRHA Surgery Program

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Introduction:

Existing data shows that 4%-16% of hospitalized patients suffer harm and surgery is involved in half of these cases. Significant improvements in the safety of anesthesia over the past three decades have contributed to the overall safety of surgery; however concern remains about the frequency of surgically-related complications. Several factors are recognized as contributing to these complications including:

·  increase in the population;

·  increase demand for surgery;

·  shortage and diversity of healthcare human resources; and

·  the continuously changing technologies/ standards that add complexity to already intricate procedures.

Note: These factors cannot be considered excuses for less than optimal surgical safety.

The Surgical Safety Checklist is:

·  a tool to promote patient safety in the perioperative period;

·  intended to give teams a simple, efficient set of priority checks for improving effective teamwork and communication; and

·  intended to encourage active consideration of the safety of patients in every operation performed.

The Checklist has two (2) purposes:

1.  Ensure consistency in patient safety; and

2.  Introduce and maintain a culture that values achieving it.

The “OR Team” is understood to include:

·  surgeons;

·  anesthesiologists;

·  nurses;

·  technicians; and

·  other OR personnel.

Although many of the steps in the checklist are already followed, rarely are all the tasks and items checked all the time by all OR teams in all facilities, because of many factors, such as time pressure, shift changes, and the presence of more than one surgical team (as in multiple trauma cases) .

The World Health Organization (WHO) lists ten (10) objectives that safe surgery should achieve (objectives are fully accepted by the Canadian Working Group).

1.  The team will operate on the correct patient at the correct site.

2.  The team will use methods known to avoid harm from the administration of anesthesia, while protecting the patient from pain.

3.  The team will recognize and effectively prepare for life-threatening loss of the patient’s airway or respiratory function.

4.  The team will recognize and effectively prepare for the possibility of high blood loss.

5.  The team will avoid inducing any allergic or adverse drug reaction known to be a significant risk for the patient.

6.  The team will consistently use methods known to minimize the possibility of surgical site infection.

7.  The team will work to avoid the inadvertent retention of instruments or sponges in surgical wounds.

8.  The team will secure and accurately identify all surgical specimens.

9.  The team will effectively communicate and exchange critical patient information for the safe conduct of the operation.

10.  Hospitals and public health systems will establish routine surveillance of surgical capacity, volume, and results.

The Checklist promotes patient safety through two mechanisms:

1.  Provides a list of tasks to be completed and items to be considered in the perioperative period. By going through the Checklist, the OR team members gain visual and/or verbal confirmation that these tasks and items have been implemented and/or addressed at various points in the perioperative period. The use of the Checklist can help to reduce the frequency of tasks and items overlooked, put off, or otherwise forgotten.

2.  The process of ensuring that each of the tasks and items has been addressed will require members of the OR team to engage in discussion about the Checklist. Discussion should also help team members understand each other’s specific roles and capabilities, foster reflection, increase communication, and strengthen the OR team.

The Canadian Patient Safety Institute (CPSI), in collaboration with the University Health Network in Toronto, has partnered with the following organizations to adapt and implement the Safe Surgery Checklist to the Canadian context:

·  Accreditation Canada

·  Canadian Anesthesiologist’s Society

·  Canadian Association of Pediatric Health Centres

·  Canadian Medical Association

·  Canadian Nurses Association

·  GreenDot Global

·  Nova Scotia Department of Health

·  Operating Room Nurses Association of Canada

·  Ottawa Heart Institute

·  Patients for Patient Safety Canada

·  Regina Qu’Appelle Health Region

·  Royal College of Physicians and Surgeons of Canada

·  Society of Obstetricians and Gynecologists

·  Suresurgery

·  University of Calgary

Successful implementation requires adapting the Checklist to local routines and expectations. Commitment is required from hospital leaders. To be successful, chiefs of surgery, anesthesia and nursing departments must publicly embrace the belief that safety is a priority and that use of the Checklist can help make it a reality.

Completion of the Checklist:

The Checklist is a verbal tool developed to support excellent patient care through good preparation and teamwork. The checklist is not intended to be part of the patient health record. The value of the Checklist is not reflected in the completion of a form and it is important to avoid the phenomenon of “tick and flick”, a process of automatically filling out a form without attention to the content or intent of the item.

The responsibility for implementing and ensuring adherence to all components of the Checklist rests with one or more representatives of the three groups of professionals who make up traditional OR teams: surgeons, anesthesiology, and nursing. The responsibility to carry out the checklist lies with ALL members of the surgical team. If reminders are required, every member of the team must feel comfortable in initiating the process.

Completion of the Checklist takes approximately three (3) to four (4) minutes.

Patient Awareness Education:

The nurse in the preoperative area shall review the purpose of the Surgical Safety Checklist with the patient during the preoperative assessment. Information reviewed with the patient should not be new information as all of the elements of the surgical checklist should have been provided to the patient during the Informed Consent process.

Components of the Surgical Safety Checklist:

The Surgical Safety Checklist is divided into three (3) components:

·  Briefing;

·  Time-out; and

·  Debriefing.

Item(s) on the Checklist (i.e anticipated blood loss) that are not applicable to the procedure being performed are not required to be completed. The Lead may be any member of the surgical team (surgeon, anesthesiologist, or nurse). The Lead is responsible to confirm with the applicable team member that each item has been addressed. A Lead has been designated for each component as indicated on the Surgical Safety Checklist.

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BRIEFING:

Briefing occurs before induction of anesthesia. At a minimum, briefing requires the presence of the anesthesiologist and nursing personnel. The Lead for the briefing is the circulating nurse or anesthesiologist.

It is essential that the patient is awake and actively participates in the Briefing component. Patient refusal to participate is required to be documented in the patient health record.

Patient Verification

·  Verbal confirmation with the patient:

o  their identity using two patient identifiers;

o  consent for surgery.

§  For elective procedures, if confirmation by the patient is not possible (i.e. children, incapacitated patient), then nursing will confirm that verbal confirmation of consent was obtained from a guardian or family member.

§  In an emergency procedure “when the patient or substitute decision maker is unable to consent and there is demonstrable severe suffering or an imminent threat to the life or health of the patient, a doctor has the duty to do what is immediately necessary without consent. Emergency treatments should be limited to those necessary to prevent prolonged suffering or to deal with imminent threats to life, limb or health. Even when he/she is unable to communicate, the known wishes of the patient must be respected. A careful and complete note should be made of this step in the patient’s health record.

o  the type of procedure planned; and

o  the site (side and/or level of surgery);

·  Site marked/Not applicable:

o  Confirm that the surgeon performing the surgery has marked the surgical site according to WHRA Policy “Correct Site, Correct Procedure and Correct Patient for Surgical Procedures (Identification of) #110.220.020”.

·  Allergies/Precautions:

o  Does the patient have any known allergies?

o  If so, what are the specific allergies? Are latex allergy precautions required? This question is asked to confirm that the anesthesiologist and/or surgeon are aware of any allergies that the patient might have. If the Lead knows of an allergy of which the anesthesiologist/surgeon is not aware, then this information shall be communicated and discussed.

o  Is the patient on any specific infection control precautions? If so what?

·  VTE prophylaxis

o  Is the patient receiving/to receive chemical (anti-coagulant) VTE prophylaxis?

·  Confirm if patient has been taking any type of anticoagulant;

·  Confirm if patient has stopped and reused anticoagulants; and

·  Confirm if heparin has been substituted and then stopped.

o  Is the patient receiving/to receive mechanical (TEDs or SCDs) VTE prophylaxis?

o  Confirm TEDs/SCDs have or will be applied as per surgeon request &/or hospital policy.

·  Equipment, Instrument(s) and/or Implant(s) Concerns?

o  Equipment:

·  This allows a chance to confirm availability of special equipment, required or as previously requested by surgeon.

·  Confirmation of the intended position is required. The circulating nurse will confirm that appropriate support and positioning devices are either in place or are available.

·  This is an opportunity for OR team members, including, where appropriate, surgical equipment manufacturing representatives, to highlight the need to discuss any problems with equipment and other preparations for surgery or any safety concerns the scrub or circulating nurse(s) may have.

o  Instrument(s):

·  This allows a chance to confirm availability of instrument(s) required or as previously requested by the surgeon.

·  Nurse verifies the sterility indicator/integrator in each package/tray. Verbally confirm that sterilization of instruments has been verified. Any discrepancy between the expected and actual sterility indicator/integrator results of the instruments should be reported to all team members and addressed before incision.

·  If there are no particular concerns, then the scrub nurse can simply say, “Sterility was verified. I have no special concerns.”

o  Implant(s)

·  This allows a chance to confirm availability of implant(s) required as previously requested by the surgeon.

·  Availability of various sizes of implants that could be used shall be confirmed.

·  Anesthesia safety check

o  Has the anesthesia safety checklist been completed in accordance with local/departmental policies, such as the Pre-Anesthetic Checklist.

·  Difficult Airway/Anesthesia Risk?

o  Confirm with anesthesia that required airway equipment is available.

o  Anesthesia shall confirm that they have evaluated the degree of difficulty of the patient’s airway and the likelihood of pulmonary aspiration of gastric contents.

·  Risk of > 500ml of blood loss?

o  May include information related to coagulation test results (PT/PTT/INR)

o  Anesthesia/Surgeon should describe any patient characteristics, medications, or morbidities (i.e. cardiac or pulmonary disease, blood disorders, etc) that may lead to complications and state his or her intention to transfuse blood products.

o  Confirm blood products are required and available.

·  If surgery may result in significant blood loss (greater than 500 ml in an adult patient), then it is highly recommended that the patient have at least two large bore intravenous lines or a central venous catheter inserted before the skin incision is made.

·  The OR team shall confirm the availability of fluids or blood for resuscitation.

o  Confirm availability of blood and blood products as required.

o  If use of a cell saver is being considered, then steps should be taken to ensure that the appropriate equipment and personnel are available and prepared.

·  Postoperative destination

o  Is the patient’s post operative destination expected to change based on information communicated in briefing?

o  If so, is a bed available in the intended new destination?

o  What factors may make the duration of the procedure unpredictable resulting in potential for change to postoperative destination?

*At this point the Briefing is completed and the team may proceed with induction of anesthesia, followed by positioning, prepping and draping.*

TIME-OUT:

At a minimum, surgeon(s), anesthesiologist(s), and nurse(s) must be present for the Time-Out. Time-out is performed after induction, prepping, and draping immediately prior to the surgical incision as per WRHA Correct Site, Correct Procedure and Correct Patient for Surgical Procedures (Identification of) policy #110.220.020. Note: Some procedures have received approval for alterations to the timing of the Time-Out i.e. ophthalmic procedures. The Lead for Time Out is the Surgeon. The order of discussion does not matter. During routine procedures or those with which the entire team is familiar, the surgeon may simply state, “This is a routine case of ‘X’ duration.

·  Team members are identified

o  Each team member is identified by Name and Role. If team members have previously introduced themselves, it is not required to repeat this step.

·  Team verbally confirms

o  Correct Patient;

o  Correct Procedure; and

o  Correct Site.

·  Antibiotic prophylaxis given within the appropriate time frame.

o  Confirm that Antibiotic Prophylaxis has been given within the last 60 minutes (exceptions Vancomycin and Fluroquinolones within 2 hours) and when next dose will be given.

o  If a prophylactic antibiotic has not been administered, administration is required before the incision is made.

o  If prophylactic antibiotic was administered more than 60 minutes (exceptions Vancomycin and Fluroquinolones within 2 hours) before the incision is to be made, the team should consider giving the patient a second dose of antibiotic.

o  Calculation of the time should also include consideration of antibiotic circulation time and duration of tourniquet time.

·  Essential imaging displayed?

o  Has essential imaging been displayed and displayed correctly.