Preventing Surgical Site Errors in Trauma Patients
Kathleen Cahill, Sara Fultz, Irene Kim, Emma Thompson, Allison Woolf
Purpose
In surgical trauma patients, does
preoperative verification versus patient
identification accuracy decrease wrong
site surgical errors?
Introduction/Background
According to Pikkel (2014)), surgical site
errors are among the most common of
surgical errors. More specifically, in traumatic
situations, stress levels are increased for
both the patient and the healthcare team.
When decisions must be made quickly, and in
situations when the patient is unconscious, it
is vital that there are protocols in place to
eliminate surgical site errors and ensure
patient safety. There is a significant amount
of literature to support the need for such
protocols. Surgical site errors can have
detrimental effects on the patient, and they
are entirely preventable.
Author, Yr.
Interventions for reducing
wrong-site surgery and
invasive clinical procedures
Algie et al., 2015
LOE V
Surgical safety checklists
briefings: Perceived efficacy
and team member
involvement
McDowell & McComb, 2016
LOE VI
Wrong-Site Surgery in
California, 2007-2014
Moshtaghi et al., 2017
LOE VI
The importance of side marking
in preventing surgical site errors
Pikkel, Sharabi-Nov & Pikkel,
2014
LOE IV
Brief report: Hospitalized
patients' attitudes about and
participation in error prevention
Waterman et al., (2006)
LOE IV
Study Purpose
- To evaluate the effectiveness of
wrong-site surgical interventions
- To examine the perceptions of
both RNs and certified surgical
technologists (CSTs) about
efficacy of surgical briefing
processes and its relationship to
team member involvement.
- The implementation of a
universal surgical safety protocol
in 2004 was intended to
minimize the prevalence of
wrong-site surgery
- To examine the frequency of
wrong-sided confusions that
could theoretically occur in
various surgeries in the absence
of preoperative verification
- To examine whether error
prevention affects patient
comfort levels during hospital
stay
Summary/Conclusion
Methods
Methods: Standardized data extraction
Study 1:
- Use of specific educational interventions in the dental from Cochrane EPOC checklists, surveys,
outpatient setting reduced the incidence of wrong-site tooth and questionnaires
extractions.
Database: PubMed, Google Scholar
Study 2:
- Implementation of the Universal Protocol reduced annual
incidence rates of wrong-site surgery in a neurosurgical
Keywords: Surgical, Error, Trauma,
population Prevent
Inclusion criteria: Research articles,
- Suggested steps be taken to identify the reasoning behind evidence-based articles, peer-reviewed
prevention discrepancies and develop educational protocols
to ensure all team members play an active role in surgical Exclusion criteria: Under 15 years,
safety practice Opinion articles, must be in English
- Common surgical site errors were operating on the wrong
side of the patients body (60 cases), performing the wrong
procedure (21 cases), operating on the wrong body part (12 Nursing Implications
cases), and operating on the wrong patient (2 cases)
Ensuring patient safety to
improve patient outcomes
Encouraging patient
- Relying on surgeons memory alone may lead to surgical participation in their care
errors, including those of wrong site Improving communication
among the interdisciplinary
- Conformation to regulations, side marking and time out
procedures are important to reduce these adverse events.
healthcare team
Implementation of standard
protocols to eliminate potential
surgical site errors
- Although patients were generally comfortable with error
prevention, their participation varied by specific action
- Educational interventions to increase comfort with error
prevention may be necessary to help patients become more
engaged