Surgical Mistakes
What are surgical mistakes?
When something about the surgery goes wrong, leading to harm, injury, or death to the patient
the surgeon and the patient
What is a surgical time-out?
last checks that verify surgery can begin.
goes in with the anesthesiologist and verifies site is marked
What organization identified "surgical mistakes" as a NPSG?
The Joint Commission
What are the three types of surgical mistakes?
wrong site
wrong person
wrong procedure
What is the best method of marking the surgical site?
the surgeon and patient's initials
When is a surgical time-out performed?
in the operating room right before incision
Who runs the electronic mediated time-out?
the nurse
What is the universal protocol?
pre-procedure verification process
marking the surgical site
surgical time-out right
When are surgical mistakes most at risk?
In cases of laterality (arms, legs, kidneys, eyes, etc.)
During what phase of surgery is the surgical site marked?
preoperative - in the preoperative holding area
Who runs the surgical time-out?
the circulator nurse
the rest of the surgical team answers
What type of nurse runs the electronically mediated time-out?
the circulator nurse
What is the goal of the universal protocol?
prevent surgical mistakes
What is a sentinel event?
An event that can lead to temporary or permanent harm or even death.
What is used to mark the surgical site?
single-use indelible ink surgical marker, a marker unable to be washed off
What does surgical time-outs verify?
right patient
right site
right procedure
allergies
medications
lab values
What is the nurses role if the wrong site is marked?
patient advocate - inform those who need to be informed
What is the gap in research on the universal protocol?
in cases of emergencies
What are ways to prevent surgical mistakes?
pre-procedure verification process
by marking the surgical site
by performing a surgical time-out
When is marking the surgical site the most important?
in cases of laterality
Why electronic-mediated time-outs?
each question needs to be answered before they can move forward. no question is missed.
If the surgeon delegates the role of marking the surgical sit to the nurse, can they mark it?
No
Clinical example of preventing surgical mistakes?
anesthesiologist coming up and doing the pre-procedure check (Sophia's patient, DO NOT ENTER patient's room)
ECT - timeout before procedure