Pennsylvania Patient Safety Advisory Rapid Response in the Operating Room Rapid response teams have proven effective for response to ORs by vascular surgeons on call to hospitalized patients in distress outside of critical cover these unique emergencies. care areas. The operating room (OR) functions The other 12 consultations that were not time- as a critical care area, as no people are better sensitive emergencies were as follows: equipped to resuscitate unstable patients in ORs than the anesthesiologists and attending surgeons. ■ An ear, nose, and throat surgeon to do an PA-PSRS staff wondered about the nature of inter- esophagoscopy to confirm an esophageal specialty consultations in the OR. laceration ■ A general surgeon to evaluate infection in a leg PA-PSRS staff examined 14 consecutive reports over with arterial insufficiency a 4-month period that included mention of intra- ■ A general surgeon to consult during a operative consultations. Only 2 of the 14 consults were time-sensitive emergencies. One involved hysterectomy an emergency right ventricular repair for a patient ■ A general surgeon to evaluate a Meckel’s diver- receiving laparoscopic-guided radio-frequency ticulum during an abdominal hysterectomy ablation of the liver by a cardiothoracic surgeon. ■ A general surgeon to evaluate an unsuspected The second involved repair of a laceration of a inguinal hernia during an excision of a hydrocele major artery by a vascular surgeon as follows: ■ A urologist to evaluate the bladder by cys- Female with diagnosis of endometrial cancer toscopy after a laparoscopic-assisted vaginal admitted for lap. Tear in the external iliac artery hysterectomy when dissecting the pelvic lymph node. Ves- ■ A urologist to evaluate the ureters after a lap- sel was clamped with vascular bulldog clamps for hemostasis. Charge nurse was informed. aroscopic-assisted vaginal hysterectomy Vascular surgeon notified. Vascular surgeon ■ A urologist to repair the bladder after a vaginal promptly repaired external iliac artery. hysterectomy PA-PSRS staff suspect that the latter is not an ■ A urologist to repair a ureter after a sigmoid unusual scenario. colon resection ■ A hand surgeon to repair a partial laceration of To identify similar situations, OR managers and/ the median nerve at the wrist or committees could review their intraoperative, ■ A vascular surgeon to evaluate an old femoral- time-sensitive emergencies requiring consultation from another surgical service. Probably, the most femoral artery bypass graft during an inguinal important will be vascular surgery assistance. If they hernia repair have not done so already, managers and/or com- ■ A vascular surgeon to evaluate a ligated mittees might consider setting up systems for rapid renal vein Vol. 5, No. 3—September 2008 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Page 89 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 5, No. 3—September 2008. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). Copyright 2008 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the PA-PSRS program, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the PA-PSRS program or the Patient Safety Authority, see the An Independent Agency of the Commonwealth of Pennsylvania Authority’s Web site at www.psa.state.pa.us. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.