Progress is a commitment
The road to improved quality often begins with a good catch, such as the one that occurred recently in the Shands at UF Operating Room and Post Anesthesia Care Unit.
By Allison Wilson
A surgeon arrived in the OR, prepared to insert tubes in the ears of an infant who was scheduled for a plastic surgery procedure later that day. But due to a scheduling glitch, the room was set up for that second procedure instead. Rather than throwing off the entire day, the team decided to perform the second surgery first. However, they were unable to complete the procedure. So they canceled it and set up the room to insert the tubes. Later, when the infant was recovering in the PACU, the parents noticed their child making gurgling noises. The surgeon checked the baby’s mouth and found a throat pack the team had inserted for the plastics procedure but forgot to remove. A throat pack is a gauze-like cloth that absorbs blood during surgery.
Fortunately no surgery was required to remove it; the child went home and had no further problems. But the team’s oversight begged investigation and reflection. “Immediately, the surgical team called a meeting, and they gathered together to discuss ways to prevent a similar event from ever happening again,” said Deborah Robins, Shands Quality Management coordinator of accreditation. “We did this within a couple hours of the event.” The discovery: In examining their process, the team realized the change in the sequence of surgical cases caused normal processes to be disjointed. The throat pack was left out of the surgical count — an inventory of items that go in the body during the procedure — a deviation from policy. The team also realized there were multiple policies on surgical counts.
The policies on surgical counts were revised and combined into one policy for all ORs on both campuses. Additionally, the team revisited scheduling processes for patients having multiple procedures. Now, when different practitioners perform procedures, the primary surgeon must make sure staff is aware there will be a second procedure to ensure the room is set up properly. The team also revised and standardized debriefing procedures for surgeries. The debriefing now includes a recheck of all counts, specimens and drains, and opportunities to ask questions or discuss unexpected occurrences. Only when this debriefing is complete can the team leave and begin their next procedure. “Within the OR, we’re really evolving our safety culture and thinking continuously about what we can we do better, not just when an event happens but in general.”