Patient safety is the hallmark of good healthcare. The Joint Commission, the Association of periOperative Registered Nurses (AORN), and the Association for Professionals in Infection Control and Epidemiology (APIC) have all made this concept a watchword for future improvements in medicine. But associations can only do so much — they can make recommendations, but not force healthcare providers to follow them.
The gastroenterology or endoscopy suite often features outpatients, who are in and out of the building in just an hour or two. Patients may have preexisting conditions or take herbal supplements that they don’t tell their nurses about, and this seemingly tiny bit of information can wreak havoc with a procedure or with the patient’s response to sedation.
Responsibility for education rests not only on the shoulders of the patient, but also on those of the staff. And patient safety in the gastrointestinal (GI) field can involve much more than inadequate bowel preps that lead to a missed abnormality.
Kris P. Kilgore, RN, BSN, is the administrative director for East Beltline Surgical Center, Inc. in Grand Rapids, Mich., and a surveyor for the Accreditation Association for Ambulatory Health Care (AAAHC). The association’s overall purpose is developing standards to advance and promote patient safety, quality, and value in the ambulatory setting.
Accuracy of information is crucial in maintaining the safety of the patient. “We verify allergies, the patient’s health history, previous anesthesia, and the age of the patient, and the anesthesia practitioner interviews each patient prior to giving them any medication,” says Kilgore. “If the patient is not able to provide us with this information, we ask the family member to help answer the health information questions. We make sure that the patient is fully alert and oriented, has stable vital signs, and understands discharge instructions.”
The concern for safety does not end when the patient is discharged, however. Kilgore believes that discharge instructions for the family and patient are essential to ensure patient safety after the client has left the facility. “The nurse goes over the discharge instructions with the patient and family,” she clarifies. “We send them home with printed discharge instructions. We also have the opportunity to go over the instructions again on their first day post-op visit in the clinic.
“We walk or wheel each patient out to the car with a nurse or nursing assistant. Because we are in the outpatient market, we use very little anesthetic. So when the patients are ready for discharge, they are fully alert and oriented.” Patients are still required to have someone else drive them home, however.
Instrument Safety and Tracking
“The management of instrument sets and equipment play an important role in a sound patient safety management program,” says Donna Gaidamak, media relations manager for Cardinal Health, referring to information about Cardinal’s OnsiteSM Services. “This importance is underscored by the frequency of patient safety incidences that occur during surgical procedures.”
For example, laparoscopic surgical procedures utilizing electrosurgery instruments can lead to stray electrosurgical burns if instruments have insulation damage. And 438,776 patients have an accidental puncture or laceration each year, with 2,500 patients experiencing an associated mortality. Pseudomonas aeruginosa and Serratia marcescens bacteria outbreaks within major hospitals have been traced back to inadequate cleaning and decontamination within certain medical procedure scopes.
Cardinal offers its OnSite Services as a solution. These services help manage instrument sets and equipment by providing resources to expeditiously clean the instrument sets after use, using equipment to detect breaks in laparoscopic instrument insulation that are not visible to the human eye. Faulty instruments and poor equipment performance are mitigated by utilizing the preventive maintenance, tray refurbishment, and education services.
Cardinal has also signed an agreement with SurgiCount Medical, Inc., to utilize the latter’s patented Safety Sponge™ System. The bar code system helps operating room (OR) staff keep track of items commonly used in surgery, working much like a grocery store check-out counter. Every lap sponge, OR towel or gauze sponge is thermally fused with a unique, patented bar code, which is scanned before and after the procedure.
Patient Privacy and Data Security
The privacy of personal patient information also falls under the umbrella of patient safety — medical personnel are not only responsible for the patient’s physical health, but also the security of personal health information, financial information, even social security numbers. Sometimes, those hired to protect the information are the worst at doing so — a computer systems administrator at pharmacy benefit manager Medco Health Solutions designed a computer program intended to destroy crucial patient information. He was charged with fraud for creating the program as revenge when he feared he would lose his job.
Government and private association laws and guidelines aim to make patient data more secure.
“The Health Insurance Portability and Accountability Act (HIPAA) governs how we call our patients pre-op and from the waiting area,” Kilgore notes. “We are very sensitive to maintaining patient privacy when they are signing into the center or signing the consent form, and when we are calling patients and their family members from the waiting room. We try very hard to maintain their privacy but make sure we have the correct patient. We check wristbands, have the patients identify themselves and their birth date once they are back in a secluded area, and verify the consent form.”
New Advances
The University of Illinois at Chicago College of Medicine (UIC) is set to develop a new patient safety curriculum. UIC received a three-year, $43 ,000 grant from the U.S. Department of Education to pilot a four-year curriculum that will adapt training and assessment tools from the aviation industry to address patient safety issues.
The project will focus on skills such as communication, teamwork, leadership and stress management identified in the aviation industry as keys to reducing errors.
The medical school is taking a proactive approach, teaching patient safety to future healthcare professionals, in the hope that they will carry these principles into their future careers. Professional standardized patients from the UIC Clinical Performance Center will be trained to portray physicians, nurses and technicians. They will give students extra experience with different scenarios including patient encounters, peer-to-peer communication, medical consultations, and surgical and other team-based activities.
In February 2006, UIC offered the first elective course in patient safety and quality outcomes to train future doctors, nurses, dentists, physical and occupational therapists, nutritionists, pharmacists and public health students.
Standards
“The same standard procedure applies to ambulatory patients and inpatients,” says Amy Baria, PCS, RN, MEd, CNAA, BC, nurse manager of endoscopy at New York’s Beth Israel Medical Center department of gastroenterology.
“Universal protocol is practiced, which means endoscopy staff (doctors, nursing and clerical staff) verify that they have the right patient, right procedure, right doctor, etc., during every step of the process, from admission/registration to initial assessment or encounter with a registered nurse (RN) or physician’s assistant (PA), intra-procedure and post-procedure discharge,” she says. Time-out protocol is followed exactly, every time.
Discharge instructions are reviewed before discharge, and the significant other or escort is informed of the instructions. “Side effects of anesthesia and/or the procedure are explained and expected with precaution: temporary forgetfulness/sleepiness; crampy feeling post-colonoscopy or mild sore throat post-gastroscopy.”
To observe HIPPAA rules properly, Baria says, “There are closed/locked recycling bins at the registration area. The interview process is conducted in an intake room one at a time; and the patient notification record (privacy act, bill of rights, hospital system notice of privacy act, etc.) is handed out and explained on admission and reinforced throughout the process.”
Most of the accreditation associations have specific instructions on following standards.
“We have a set of standards related to the recovery room and discharge procedures,” confirms Jaime Trevino, a spokesperson for the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). “As always, if there are any federal, state or local regulations regarding any aspect of outpatient surgery, those will come into play if they are more stringent than those of AAAASF.”
AAAASF requires that all facilities follow the strictest standard or requirement under all circumstances, Trevino adds. “We do not have standards that are discipline-specific, but try to have a valuable set of standards that would help outpatient facilities improve patient safety.”