Outpatient Surgery Magazine

Queasy Feeling - April 2017 - Subscribe to Outpatient Surgery Magazine

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

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immediately after injecting the patient and notified the surgical team. The anesthesiologist promptly administered lipids, and the patient was unharmed. The tech had followed the hospital's policies for the proper labeling and transfer of medications on the sterile field, but a potentially fatal error still came this close to occurring. Our review of the incident uncovered process improvements we needed to make, but also revealed plenty that went right to prevent patient harm. Here are 6 lessons we learned from the event that we hope you can incor- porate into your medication safety efforts. 1. Create a hard stop. Put mechanisms in place to fix a faulty system that creates the possibility of human error. In our case, the surgical tech and the circulating nurse visually and verbally confirmed all medication delivered to the sterile field, including the contrast dye and local anesthetic. During our root cause analysis of the near miss, we decided that our medication labeling and handling policies weren't enough to prevent the surgical tech from drawing up the wrong drug, so we implemented a hard stop for whenever multiple agents are on the sterile field. We now house local anesthetics in a lidded specimen cup instead of in an open Pyrex cup. The cover acts as a hard stop by creating a deliberate step in the process of drawing up meds; techs now pause for a second or two to consider if a local anesthetic is in fact the agent they want. We added additional specimen cups and lids to our procedure packs, so the surgical team has enough containers to implement the hard stop. We also taught every surgical tech about the new policy, had them sign off on their understanding of it and audited their practice for 6 months to ensure they complied with the new directive. 2. Act quickly and decisively. Have a safety reporting system in place, so you learn about mistakes and near misses in real time. Funnel the A P R I L 2 0 1 7 • O U T PA T I E N TS U R G E R Y. N E T • 1 2 9

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