Patient Safety Advisory Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) Produced by ECRI & ISMP under contract to the Pennsylvania Patient Safety Authority The Need for Surgical Preparation S urgeons understand the need to be properly trained to do a procedure. They also understand the need for a preoperative “time out” to verify that the resentative of a medical device manufacturer. According to the facility’s report, the surgeon was “trying to figure out how to use [the] Neuro correct patient is getting the correct procedure on the Navigator system.” correct part of the body. However, preparation in- cludes more than training and “time outs.” Consider Preoperative preparation by the surgeon may need to these recent reports to PA-PSRS: go beyond verifying the consent and the correct pa- tient, the correct procedure, and the correct site. A Case #1: A surgeon scheduled a patient for comprehensive preoperative checklist could also in- elective closure of a cranial defect from prior clude: surgery. The surgeon brought prosthetic mate- rial to the operating room for the closure, but it • Re-assessment for recent changes in the pa- was material suitable for temporary closure tient’s condition. only, not permanent closure. The error was recognized before the operation began, and • Verification of the indications for the operation the procedure was cancelled and rescheduled. with adequate information about the extent and exact location of the pathology available in the Case #2: A patient with an acute left femoral operating room for possible intra-operative deci- artery occlusion was brought to the operating sion making. room after confirmatory angiography. The con- • Review of the patient’s other medical conditions, sent for thrombectomy, obtained as an emer- allergies, and medications, including medications gency by someone other than the surgeon, at the time of surgery, such as prophylactic antibi- erroneously listed the wrong leg. The pre- otics. operative “time out” was done with the sur- geon, but based on the incorrect consent. • Confirmation that essential materials, such as While making the initial incision, the surgeon blood products, implants, or prostheses, are avail- remembered that the occlusion was in the left able. leg. To reconcile the conflicting information, he • Confirmation that essential equipment is working had the films brought to the operating room. properly. The films confirmed his recollection, so he closed his skin incision and proceeded to do • Discussion with the team of possible intra- the thrombectomy on the correct leg. operative complications and how they should be managed. Case #3: A surgical patient was kept under general anesthesia for two hours before their operation was begun. During this time the sur- geon was on the phone with the technical rep- This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 2, No. 1—March 2005. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI & ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). Copyright 2005 by the Patient Safety Authority. This publication may be re- printed 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. To see other articles or issues of the Advisory, visit our web site at www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. ©2005 Pennsylvania Patient Safety Authority Page 1 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) An Independent Agency of the Commonwealth of Pennsylvania 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, as contractor for the PA-PSRS program, is issuing this newsletter 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 Authority’s website at www.psa.state.pa.us. ECRI is an independent, nonprofit health services research agency dedicated to improving the safety, efficacy and cost-effectiveness of healthcare. ECRI’s focus is healthcare technology, healthcare risk and quality management and healthcare environmental management. ECRI provides information services and technical assistance to more than 5,000 hospitals, healthcare organizations, ministries of health, government and planning agencies, and other organizations worldwide. 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 non-punitive approach and systems-based solutions. Page 2 ©2005 Pennsylvania Patient Safety Authority