Patient Safety Advisory Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 2 (June 2005) Produced by ECRI & ISMP under contract to the Pennsylvania Patient Safety Authority Tips from PA Facilities: Enforcing the Time Out and Preventing Retained Foreign Bodies O n occasion, reports submitted to PA-PSRS in- clude the results of the facility’s root cause analysis (RCA) and systems-level solutions for ad- This solution is a good example of a “forcing func- tion.” The Agency for Healthcare Research and Qual- ity (AHRQ) Patient Safety Network (PSNet), defines a dressing a patient safety issue. In rare instances, the forcing function as “an aspect of a design that pre- solution to a problem presents itself immediately, and vents a target action from being performed or allows the facility shares this information with PA-PSRS in its performance only if another specific action is per- their original report. More often, though, these formed first.”1 An example cited by PSNet is the elimi- “pearls” are submitted in amended reports after a nation of concentrated potassium from floor stock thorough investigation and, in some cases, an RCA. medication cabinets. Forcing functions take different shapes such as “lockins” which prevent exiting until When facilities share their experience through PA- safe; “lockouts” prevent access until conditions are ac- PSRS, Patient Safety Officers, clinicians, and other ceptable and; “interlocks” which require a specific order of healthcare workers can make a difference not only in events or sequencing.2 their own organizations but in healthcare facilities across the Commonwealth. With respect for your con- Other common examples of forcing functions include: tributions and efforts to find innovative solutions, we are happy to share these “lessons learned” with your • CPOE systems that require blood glucose moni- colleagues throughout Pennsylvania. toring when insulin is administered or stop an insulin drip (with physician notification) when an Surgical Prep Redesign to Enforce the Time Out NPO order is entered.3,4 Reports submitted to PA-PSRS of both actual and • Medical gas cylinders are accessed by a specific “near miss” wrong patient, wrong site, and wrong pro- pattern of holes with matching pins from the ap- cedure surgeries suggest that the practice of the time propriate regulator. This “Pin Index System” out before surgery has become widespread. How- helps ensure that the patient doesn’t get nitrous ever, several reports indicate that the surgeon some- oxide rather than oxygen by preventing the user times begins the procedure before the time out is per- from getting the lines crossed.2 formed. A “procedural forcing function” is weaker than a me- In one such case, the surgeon started operating on chanical or physical one, as it relies on a process the wrong hand prior to the time out. An amendment where human actions are interdependent and thus to the facility’s original PA-PSRS report indicates that lacks the mechanics of a failsafe design. Procedural the facility changed their pre-surgery process to mini- changes fall into this category.2 The practice of not mize the potential for the procedure to begin without a attaching the handle and scalpel until the time out is time out: The surgical blade is not attached to the performed is an example of a procedural forcing func- scalpel handle until after the time out is performed. tion. Other examples include the pre-surgery time out itself and blood product verification by two people.2 This same suggestion surfaced in a similar report from another facility that reported a near miss indicat- ing that not all staff members were informed of a new This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 2, No. policy requiring the time out to precede the placement 2—June 2005. The Advisory is a publication of the Pennsylvania Patient of the blade in the scalpel handle. Safety Authority, produced by ECRI & ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). Notice that this simple suggestion doesn’t add any Copyright 2005 by the Patient Safety Authority. This publication may be re- steps to the process. It doesn’t require any new tech- printed and distributed without restriction, provided it is printed or distributed in nology, increase costs, or cause a delay in the proce- its entirety and without alteration. Individual articles may be reprinted in their dure. Simply reordering the existing steps provides an entirety and without alteration provided the source is clearly attributed. additional safety barrier between the patient and the To see other articles or issues of the Advisory, visit our web site at inevitable human error. 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. 2 (June 2005) Tips from PA Facilities: Enforcing the Time Out and Preventing Retained Instruments (Continued) The Surgical Towel as Retained Foreign Body These actions may help to prevent surgical towels Numerous reports have been submitted to PA-PSRS of from becoming retained foreign bodies: discrepancies related to instrument, sharp and sponge counts. Frequently, these case reports indicate that a • Incorporating the AORN standards into surgi- radiograph was used to confirm the absence of a retained cal policies and procedures. foreign body. Most instruments and sharps are ra- diopaque. Objects introduced into the body that are not, • Using commercially available towels with ra- such as sponges, have radiopaque markers to facilitate diopaque detectable strips designed specifi- identification on a radiograph. cally for packing.5 A recent case submitted to PA-PSRS reported identi- • Independent inspection or exploration of the fication and removal of a surgical towel left from a operative field by the surgeon either routine- procedure that occurred two years earlier. Sterile sur- ly7,8 or following procedures that are known gical towels are draped around the wound to minimize for risk of retention of a foreign body, such as contact with the skin. Because they are not intended emergent cases, those cases with unplanned for use within the wound, they typically do not have changes in procedure, and when the patient radiopaque markers as surgical sponges do. How- has a high body-mass index.9 ever, occasionally towels are dislodged or are used to cover the wound during intra-operative radiographs or Notes 1. Patient Safety Net: Glossary. Agency for Healthcare Research to cover organs, displaced onto the operating surface and Quality [online]. [Cited 2005 Apr 22.] Available from Internet: to facilitate exposure, in order to decrease evapora- http://psnet.ahrq.gov/glossary.aspx. tion from their moist surfaces and prevent desicca- 2. Gaba DM. Thin air. Web M&M: Morbidity and Mortality Rounds tion. on the Web [online]. Agency for Healthcare Research and Quality. 2004 Oct [Cited 2005 Apr 22.] Available from Internet: http:// webmm.ahrq.gov/case.aspx?caseID=76. The facility reporting this occurrence to PA-PSRS responded to this hazard by changing to radiopaque 3. Cucina R. The forgotten med. Web M&M: Morbidity and Mortality Rounds on the Web [online]. Agency for Healthcare Research and towels and by taking the following actions to help pre- Quality. 2005 Apr [Cited 2005 Apr 22.] Available from Internet: vent recurrence: http://webmm.ahrq.gov/case.aspx?caseid=93. 4. Rubin HR, Fajtova VT. Too tight control. Web M&M: Morbidity • Using radiopaque towels when towels will be and Mortality Rounds on the Web [online]. Agency for Healthcare placed in a body cavity Research and Quality. 2004 May [Cited 2005 Apr 22.] Available from Internet: http://webmm.ahrq.gov/case.aspx?caseID=60. • Including towels used in open wounds as part 5. Petersen C. AORN journal: September 2001 clinical issues. of routine sponge/instrument counts. AORN [online]. 2001 Sep 1 [Cited 2005 Apr 27.] Available from Internet: http://www.aorn.org/journal/2001/sepci.htm. The Association of PeriOperative Registered Nurses 6. Samples C, Dunn E. Reducing the vulnerability of retained surgi- (AORN) supports this approach: “If a towel is used for cal sponges. NCPS TIPS (National Center for Patient Safety), Sep/ packing, the scrub person must inform the circulating Oct 2004. nurse, who must add the towel to the count sheet. 7. Kaiser CW, Friedman S, Spurling KP, et al. The retained surgical sponge. Ann Surg. 1996;224:79-84. The closing count includes verification that the towel 8. Hyslop JW, Maul KI. Natural history of the retained surgical has been removed. A better alternative is to use sponge. South Med J. 1982;75:657-60. commercially available towels that have x-ray detect- 9. Gawande AA, Studdert DM, Orav JE, et al. Risk factors for re- able strips and are designed specifically for packing.”5 tained instruments and sponges after surgery. NEJM 2003 Jan;16 (348):229-35. The Veterans Administration’s National Center for Patient Safety also suggests that, “Without exception, all sponges and towels should have radiopaque mark- ers.”6 Page 2 ©2005 Pennsylvania Patient Safety Authority Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 2 (June 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. ©2005 Pennsylvania Patient Safety Authority Page 3