the heart of a healthy community23 the heart of a healthy community • new hire orientation,...

Teamwork in the

Operating Room

www.arrowheadmedcenter.org

Mark E. Comunale, M.D. Chief Medical Officer for Patient Safety

Chair, Department of Anesthesiology, ARMC

Professor of Anesthesiology, LLUMC

The Heart of a

Healthy Community

June 10, 2015

Teamwork is:

People + Policies + Procedures +

COMMUNICATION

www.arrowheadmedcenter.org The Heart of a

Healthy Community

Teamwork

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| 3 Communication Issues Leading Factor in Root Causes


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Collation of sentinel event-related data reported to The Joint Commission (1995-2005).

http://www.jointcommission.org/SentinelEvents/Statistics/

http://www.jointcommission.org/SentinelEvents/Statistics/

All High Reliability Organizations Have

Mastered Communication


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Communication

Mastering Communication in the OR


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Communication

| 6 Procedural Time-Out


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• Find the leaders

• Creating Buy-In

| 7 Procedural Time-Out: Video Production


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“Time-Out”

Who are the unofficial leaders? Surgeons Nursing Anesthesiology All staff present for filming. Have script and follow along. Several groups participate in filming. Accomplishes education and teamwork training at same time.

| 8 Procedural Time-Out: A Tool for Conversation


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“Time-Out”

• Rolled out in OR first. • Buy-in and education about the

process initiated by use of video production using OR staff, anesthesiology and surgeons.

• “Time Out Sheet” created based on

video. • Check list on one side, scripted on

reverse.

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Standardized Script for Time-Out



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Who does it? • The “Team” does it • The team will perform a time-out



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Circulating Nurse

• The circulating nurse initiates and runs the time-out process

• She/he has been given the responsibility and AUTHORITY to run the time-out.

• What does “Authority” mean? • Must be supported when they

stop the train

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| 13 Procedural Time-Out Common Problem


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The phenomenon of Protocol Drift The use of memory

The intentional or unintentional designee Skipping steps in process


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The Joint Commission

2006 National Patient Safety Goal– 2E (Now a Joint Commission standard)

Implement a standardized approach to “hand-off” communications including an opportunity to ask and respond to questions

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| 15 Hand-off Concepts


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High Reliability Organizations

⁻ Nuclear Power

⁻ NASA and Mission Control

⁻ Aviation: Crew Resource Management ⁻ Air traffic control- LAX ⁻ Carrier flight deck

⁻ Dispatch services

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| 16 Hand-off Concepts


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High Reliability Organizations

⁻ Have mastered communication BUT…

⁻ Look at their processes:

⁻ They do the same thing, the same way, every time, all the time.

⁻ They learn from their mistakes and change their processes/procedures. Think RCAs!

⁻ Virtually no variability.

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| 17 I – SBAR- Q: A Tool to Guide a Conversation


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I – ntroduction S - ituation (the current issue) B - ackground (brief, related to the point) A - ssessment (what you found/think) R – ecommendation/request (what you want next) Q- uestions

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ISBARQ I- Introduction S- Situation B- Background A- Assessment R- Recommendation Q- Questions

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| 21 Pause for Transfer Of Care


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• Who does it? • The “Team” does it

• The team will perform Pause for

Transfer of Care

•

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| 22 Physicians Role


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• Find the Holes • Physicians should lead the process

• Change the Culture

• Educate your colleagues • Ensure compliance with National Patient

Safety Goals

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• New hire orientation, introduction to patient safety

• Patient Safety Grand Round lectures for all staff

• Charge Nurse classes with emphasis on patient safety

• Patient Safety computerized education for Nurses (patient safety basics)

• Patient Safety Rep training for Nurses • Sim. Lab for Residents & Nurses, focused on

high risk patient safety goals such as: 2 patient identifiers, Hand-hygiene, Medication Administration, High Risk Medication Administration

Patient Safety Education

Education

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| 24 Patient Safety Grand Rounds


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• Conducted quarterly

• Multidisciplinary

• In-depth coverage of topics such as:

• RCA

• FMEA

• ISBARQ and other tools

• Always cover SAE dashboard and have informal discussion regarding the events.

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0

1

2

3

4

5

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JUL AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUN JUL

ARMC SAE DASHBOARD 2013-2014

Death

Serious Harm

No Harm

Near Miss

Color coded stick figures

identify the event, and

how many events

occurred during the

month

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• New hire orientation, introduction to patient safety

• Patient Safety Grand Round lectures for all staff

• Charge Nurse classes with emphasis on patient safety

• Patient Safety computerized education for Nurses (patient safety basics)

• Patient Safety Rep training for Nurses • Sim. Lab for Residents & Nurses, focused on

high risk patient safety goals such as: 2 patient identifiers, Hand-hygiene, Medication Administration, High Risk Medication Administration

Patient Safety Education

Education

• What is the institutions expectation?

• How (specifically) is it demonstrated to

employees?


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Training

Focus on the process as well!

How do you do your work?

Train (and create your policies) based on how

you do your work.


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Communication

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| 30 Patient Identification


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ARMC’s Expectation:

EVERY TIME YOU INTERACT WITH PATIENT!! You will: • Use minimum of Name and Date of Birth (DOB) • Do not ask by “leading” • Do not refer to patients as room numbers (“the patient in 5102”)

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| 31 Patient Identification


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Specifically, we want you to say/do the following:

Say: Hello, my name is_________

Do: reach for and read the patient’s ID band

Say: Can you tell me your name and date of birth

please?

Do: Verify patient’s verbal response against ID band

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| 32 Basic Bedside Safety Skills Simulation


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Process: (nursing) 1. Basic Skills Identified

Hand-Hygiene

Patient Identification

Medication Administration Process

High Risk Medication Administration Process

2. Simulation Session Construction

Each process mapped from policy/protocol

Observer check list created

Volunteers for patients

Pharmacy created test patient ID for pyxis access/scanning


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2 patient Identifiers Data after Sims. Training

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2 Patient Identifiers

Goal

Patient Safety Rounds

Patient Safety Rounds +Patient Safety Reps

98%

Nursing SIM Training


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Hand-Hygiene Data after Sims Training

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hand Hygiene

Goal

Patient Safety Rounds

Patient Safety Rounds +Patient Safety Reps

95%

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Communication

There are some things that good communication will not fix.

There are some things that good policies will

not fix.

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ABO Compatibility

• Trauma patient in OR.

– ABO = AB

• Massive Transfusion Protocol initiated

• Blood bank tech removes type A FFP from fridge by mistake and sends

• Member of anesthesia team has prior experience from another institution.

• Does not check with BB before transfusing

What is our institutions knowledge regarding ABO compatibility?


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DONOR PRBC


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DONOR FFP


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ABO Quiz Results

Comunale, ME et al. J. Patient Safety. 6/15 (published ahead of print)


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ABO Quiz Results

Nursing Surgical Techs Physicians


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ABO Cognitive Aid

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Blood Release Request Forms


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ABO Cognitive Aid

62 y.o. male in OR for ORIF R hip.

Uneventful induction/antibiotic admin.

During a-line placement, team notes red blotches.

Hypotension/tachycardia unresponsive to phenylephrine ensue.

Allergic reaction diagnosed.


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Communication Case Review

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Cognitive Aids Table of Contents

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Cognitive Aids

| 51 Cognitive Aids


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ARMC CODE BLUE COMMITTEE

ACLS Algorithms and Treatment Modalities

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Cognitive Aids

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Questions?

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