POLICIES & PROCEDURES ON PREVENTION ON ADVERSE EVENT IN SURGICAL PATIENT

 

POLICIES & PROCEDURES ON PREVENTION ON ADVERSE EVENT IN SURGICAL PATIENT

Policy:

 

Personnel involved in care of surgical patients shall take all necessary measure to reduce the risk of occurrence of adverse events in surgical patients.

 

Adverse event in surgical patients those preventable are occurred due to neglect, human errors or due to improper co-ordination. For e.g. Surgery on wrong site, surgery on wrong patient, or wrong surgery on the patient.

 

Any adverse event with surgical patient shall be reported to hospital management and to safety committee. The committee shall do a root cause analysis and take appropriate preventive measures to prevent occurrence of similar event in future.

 

Following are re-emphasized for surgical patients

 

1. Proper identification of the patient (through identification tag, name and medical record)
2. Proper identification of the site (through site marking)
3. Proper identification of surgery to be performed (through medical record)
4. Proper co-ordination between ward / ICU staff, OT staff, medical officers, Anaesthesiologist and consultant surgeon.

 

Procedure:

Sr. No	Procedure Steps	Responsibility
	Scheduling: The following information is must when scheduling an invasive/surgical procedure: Ø  Correct spelling of the patient’s full name Ø  In-patient number Ø  Consent for Procedure to be performed.	Primary Nurse
	Any discrepancies should be clarified with consultant	Primary Nurse
	Pre-procedure/preoperative verification The physician & anaesthetist will verify patient’s identity by asking •      Patient’s full name •      Date of birth •      Procedure/surgery to be performed. If patient is minor, incompetent or sedated, or not able to speak then in such case ask the near blood relative or legal guardian to give the details.	Physician & anaesthetist
	Site mark: Preferably, completed before patient enters procedure/operating room. Site mark is required in invasive/surgical procedure that involves: Ø  Laterality (e.g. right, left) Ø  Multiple structures (e.g. toes, fingers, limbs) Ø  Multiple levels (e.g. spine) Ø  Includes bedside invasive procedure.	Physician & anaesthetist Primary Nurse OR nurse/registrar
	Procedures exempt from the site marking are. Ø  Endoscopies Ø  Tonsillectomy Ø  Haemorrhoidectomy Ø  Single organ cases (e.g. cardiac surgery) Ø  Teeth Ø  Interventional cases for which catheter and instrument site is not predetermined (e.g. Central line, cardiac catheterisation). Ø  Premature infants.
	Prior to making the site mark the consultant erforming the procedure/surgery verifies the patient’s identity and medical records. In case of minor verification process must involve parents or legal guardian.	Physician & anaesthetist
	If a telephonic site marking verification is obtained, the doctor who is the witness should ask the next of kin the identification of the person on the telephone, the relationship, patient’s date of birth, procedure and procedure site.	Witnessed Physician or any Doctor
	There should be a standardize marking for all the procedures (e.g. SS – surgical site). The marker should be hypo allergic, latex free, and sterile. The marking should be clear and unambiguous.	Infection Control Nurse OR nurse/registrar
	If patient refuses for site marking, patient’s consultants should be informed and documented in the patient’s medical record	Physician & anaesthetist OR nurse/registrar
	The site mark should not be removed until the procedure is over	Physician & anaesthetist OR nurse/registrar
	Time out procedure: Time out is required for confirmation of: Ø  Correct Patient Ø  Correct side/site Ø  Correct procedure Ø  Correct patient position Ø  Correct radiographs Ø  Correct implants and equipment
	A verbal “time out” or pause is called by OR nurse/registrar immediately before the rocedure/surgery in the operating oom/procedure room.	Nurse /registrar
	The patient doses not have to be awake for the time out”. Site marking must be visible at the time of “time out” or pause.	Nurse /registrar
	As soon as patient enters the operating/procedures room the OR nurse/registrar assigned for calling “time out” will call for a pause and he/she will loudly call the full name of the patient, in-patient number, procedure name and site.	Nurse /registrar
	The scrub nurse, anesthetist and surgeon will say yes to all the details. “Time Out” will be documented in the medical records. It should include: Ø  Personnel present at the time out Ø  Verification of correct Patient Ø  Verification of correct side and site Ø  Agreement on the procedure/verification of radiographs Ø  Verification of the correct position Ø  Available implants and equipments	Physician & anesthetist OR nurse/registrar
	Discrepancies If any discrepancy is found at any point, the case ust stop from proceeding until resolved.	Physician & anesthetist, OR nurse/registrar
	All team members and patient (if possible) must agree on resolution to the identified discrepancy. The attending consultant in patient’s medical records must document discrepancy and resolution.	Attending Consultant (Physician & anesthetist)

 

 

Quality Assurance Programme- Surgical Services

 

v Quality assurance for Surgical Services:

 

Condition for Coverage: Surgical procedures must be performed in a safe manner by qualified physicians who have been granted clinical privileges by the governing body, in accordance with approved policies and procedures.

 

Ø       Interpretive Guidelines: “In a safe manner” means that:

•      The equipment and supplies are sufficient so that the type of surgery conducted can be performed in a manner that will not endanger the health and safety of the patient;

•      Access to operative and recovery areas is limited.

•      All individuals in the surgical area are to conform to aseptic techniques.

•      Appropriate cleaning is completed between surgical cases i.e complete pre-operative preparation before patient is shifted to O. T

•      Suitable equipment is available for rapid and routine sterilization of operating room materials;

•      Sterilized materials are packaged, labeled, and stored in a manner to ensure sterility and that each item is marked with the expiration date; and

•      Operating room attire is suitable for the kind of surgical cases performed. (Persons working in the operating suite must wear clean surgical costumes in lieu of their ordinary clothing. Surgical costumes are to be designed for maximum skin and hair coverage.)

 

For the sterility of the OT & from infection control point of view following should be taken care of:

 

•      Weekly Air culture, Weekly fumigation

•      Hypochlorite treatment of infected linen / instruments for 3 – 4 hrs before autoclaving.

•      Restricted entry of visitors into O.T. complex

•      OT turnaround time should not be more than 30 minutes.

 

Ø       Anaesthetic Risk and Evaluation:

 

A physician must examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed. Before discharge from the Hospital, each patient must be evaluated by a physician for proper anesthesia recovery.

 

The medical record should confirm:

 

•      If laboratory studies were ordered as part of patient evaluation. The report should be part of the medical record or notation of the findings recorded on the chart.

•      For general anesthesia, the evaluation should contain, at a minimum, a brief note regarding the heart and lung findings the day of surgery; and

•      Depending on the type of anesthesia and length of surgery, the postoperative check should Include some or all of the following:

Ø  Level of activity;

Ø  Respirations;

Ø  Blood pressure;

Ø  Level of consciousness; and

Ø  Patient colour.

 

Ø  Administration of Aesthesia:

 

•      Anesthesia must be administered by only:

1)      A qualified anesthesiologist, or

2)      A physician qualified to administer anesthesia, a certified registered nurse

Anesthetist, a supervised trainee in an approved educational program, or an anesthesiologist’s assistant. In those cases in which a non-physician administers the anesthesia, the anesthetist must be under the supervision of the operating physician, and in the case of an anesthesiologist’s assistant, under the supervision of an anesthesiologist.

 

Summarization of the Activities in accordance with roles and responsibility:

 

S. No	Key Characteristics	Acceptance Norms / Criteria	Responsibility And Conformance Verification	Frequency
1.	Punctuality of O. T staff	Start functioning at time	OT in charge	Daily – See the register
2.	Complete pre operative preparation before patient is shifted to O. T	•     Part preparation •     Removal of all ornaments. •     Consent for •     procedure •     Change of clothes.	O.T. Staff	Daily
3.	Anesthesia induced after 17.00 hrs.	Acceptable only during emergency	Anesthesiologist	Once in a week
4.	Cases continuing beyond 19.00 hrs.	Acceptable only when necessary	Anesthesiologist	Once in a week
5.	Infection Control and sterility of O. T	•    Weekly air culture •    Weekly fumigation •    Hypochlorite treatment of infected •    linen / instruments •    for 3 – 4 hrs before •    autoclaving. •    Restricted entry of •    visitors into O.T. •    complex	OT in charge / O.T. Staff / Anesthesiologist	Once in a week
6.	O. T turn around time between two operations	Not more than 30 mins.	OT incharge and anaesthesiologist