Imagine that you are working a hectic shift on a Monday morning at a regional surgery center. As you prepare for your next case, you read the surgical posting that states patient Thomas is to receive a total joint replacement of the right knee. The patient arrives late, and the preop nurses are busy with a record volume of cases. He is given a marker to indicate his surgical site, but he marks his left knee instead of the right. The charge nurse assesses the patient for you as you make other preparations since the case is running behind and the surgical team is eager to get started.

After the patient is anesthetized, you place the tourniquet on his right knee, complete the skin preparation, and prepare the equipment. You then notice that the patient had marked his left knee, so you question the surgical team. The surgeon insists that the left knee is the knee to receive the replacement. X-rays of the patient’s left knee are hanging on the view box. As the case progresses, you review the patient’s medical record and find that the patient has signed a consent for a total joint replacement of the right knee. Upon further investigation, you find the X-rays hanging on the view box are not the patient’s.

Unfortunately, cases like this are not infrequent. Unless a team member recognizes and corrects the error, patient injury will result. As we review the facts of this case, a number of questions surface. Could this situation have been prevented? What steps should the surgical team have taken to ensure the patient’s safety? This module will inform nurses of the evidence-based steps to take to create a culture of safety in the OR.

Patient safety in the OR is not a new concept to healthcare providers, especially perioperative nurses. In 1943, Edythe Louise Alexander, author of what has come to be known 13 editions later as Alexander’s Care of the Patient in Surgery, referred to the nurse’s role in “safeguarding the patient” in collaboration with other members of the healthcare team.¹ The perioperative nurse plays a significant role in the surgical process, including ensuring the correct operative site, operating an extensive array of equipment, and validating patient identifiers before the administration of blood.¹

Alexander’s admonitions remain relevant today, but the focus on patient safety has expanded beyond single departmental standards. Providing a safe environment for patients is now recognized to be more than a collection of individual efforts. The safe environment extends to the work context or culture of an organization.²

The focus on a culture of safety gained impetus after the 2000 publication of the Institute of Medicine’s To Err Is Human: Building a Safer Health System.³ The wide media coverage of the IOM report prompted closer scrutiny of healthcare errors and methods to reduce errors. As the cultural aspects of health care have become better appreciated, several dysfunctional forms of “culture” have been recognized —

• Shame and blame: Bad people make mistakes and must be punished; failure (and error) lies with the individual; historically, the most common culture.
• Secrecy: Don’t air dirty laundry in public; if we don’t talk about mistakes, no one will know we made them.
• Blame-free culture: With the IOM’s report revealing that many errors are systems problems, some organizations have promoted a culture of “no individual blame.”³

A more reasonable and effective way to create a culture of safety is to promote a “just culture” — one that balances systems weaknesses with personal accountability.⁴

Effective safety cultures have certain common attributes, including —

• Recognition of the high-risk, error-prone nature of the organization’s work
• An environment where people can report errors, close calls, and near misses without retribution
• Multidisciplinary collaboration in seeking solutions to potential sources of error
• Organizational use of resources to enhance safety⁵

Organizational culture (a group’s behavior and attitudes) can influence the safety of an environment.⁶ A positive safety culture is characterized by communication based on trust, a shared belief that safety is important, and confidence that preventive measures can — and will — work.⁷ (See the sidebar for employee and organizational attributes of an effective safety culture.)

Working for safety

Many organizations provide resources to help create a culture of patient safety.⁸ These organizations include the Institute for Healthcare Improvement (IHI), the Surgical Care Improvement Project (SCIP), the Agency for Healthcare Research and Quality (AHRQ), and the Association of periOperative Registered Nurses (AORN). The IHI has been a major force in the safety movement. It developed the 100,000 Lives campaign, which was such a success that it inspired a new campaign, Protecting 5 Million Lives from Harm. Like many safety organizations, the IHI is working to reduce variability in healthcare systems, such as the surgical process (variability increases the risk for error); minimize the risks associated with medical mistakes; and promote interventions that reduce errors and patient harm. Among these interventions are rapid response teams, medication reconciliation, and the prevention of catheter-related central line infections and surgical site infections.⁹ 

The prevention of surgical site infection is the goal of the SCIP, a partnership of national organizations whose goal is a 25% reduction in surgical complications.¹⁰ Of particular interest to the SCIP are surgical site infections, cardiovascular complications, venous thromboembolism, and postoperative ventilator-associated pneumonia. SCIP member organizations include the IHI, the AHRQ, AORN, the American College of Surgeons, the American Hospital Association, the American Society of Anesthesiologists , the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services, the Joint Commission www.jointcommission.org, and the Veterans Health Administration. 

The AHRQ has an extensive array of professional and consumer resources, including patient safety culture survey tools to assess an organization’s safety culture. A database report is also available that compares participating hospitals. The National Patient Safety Foundation improves safety through publications and meetings that study why errors occur and what safeguards can be put into place to prevent injury to patients. Providing tools, education, and hands-on learning opportunities, the Institute for Safe Medication Practices www.ismp.org  has been at the forefront of efforts to increase awareness of medication errors and adverse drug events.

Of special interest to perioperative nurses is the AORN’s role in promoting patient safety through its standards, recommended practices, guidelines, and tool kits.¹¹ Tool kits for correct site surgery, medication safety, and fire safety are available online.¹² AORN’s Just Culture Tool Kit is especially useful for establishing a safe environment based on the principles of a just culture. (See the sidebar “Creating a Patient Safety Culture.”)

Error-prone

The OR is a complex setting, with high-tech demands and team members with varying competencies working on cases that are often emergent or urgent. These factors make the OR prone to errors, which are more likely to occur during periods of procedural confusion and deviation from protocol. These adverse events include wrong site/wrong procedure surgeries, retained sponges, unchecked blood transfusions, mismatched organ transplants, overlooked allergies, incorrect counts, equipment malfunction, and medication errors. Surgical fires and patient falls are other high-risk outcomes included in the National Patient Safety Goals.^13-15

Beyond national efforts, the international community of Canada, Germany, the Netherlands, New Zealand, Australia, the United Kingdom, and the United States have committed themselves to improve patient safety globally by signing the World Health Organization Action on Patient Safety. This program involves developing standardized protocols to address five widespread patient safety problems, including wrong site/wrong procedure/ wrong person surgical errors.¹⁶

Communication breakdowns are also a major cause of errors. According to The Joint Commission, communication is the leading cause of sentinel events, despite the implementation of the universal protocol.¹⁷ A study to classify OR communication found 30% of the relevant exchanges among team members contained some type of communications failure.¹⁸ Another study reported that more than 50% of errors in surgery were a direct result of a breakdown in communication or lack of communication between team members.¹⁹ The nursing staff’s accurate transmission of preop assessment information, along with patients’ involvement in their own care, can reduce the incidence of wrong site surgery.²⁰ Improvement is needed in communication and teamwork. Examples of strategies to improve communication include having an OR briefing to discuss the operative plan and allowing the OR team to discuss potential problems before they lead to a near miss or actual harm.¹³

National efforts are under way to link safe care to reimbursement. The National Quality Forum has developed a list of “never events” that are serious and costly and should never occur.^21,22 Included in this list are surgery-related events (retained foreign objects and wrong site surgery). One researcher reviewed the literature about methods to prevent wrong site operations and “never events” within institutions, and found that little was known about adherence to existing policies.²³ Each organization should be encouraged to review policies related to reducing adverse events in surgery and rely on policies that foster teamwork and communication to create a culture of safety.

Speaking the same language

Standardized perioperative language helps improve incident reporting and could improve perioperative patient safety.¹⁴ The Perioperative Nursing Data Set (PNDS) offers standardized language for nursing interventions and expected outcomes that has the potential to influence the culture of safety in the OR. The PNDS provides a taxonomy that describes perioperative patients’ experience from preadmission to discharge. It was the first specialty language recognized by the American Nurses Association.²⁴

The PNDS can be used to provide uniform perioperative documentation related to the safe patient environment. Uniform documentation fields are the foundation for the successful exchange of data and can support evidence-based healthcare processes and outcomes analysis. (See the sidebar “Examples of PNDS Outcomes, Definitions, and Interventions.”)

Without a safe culture in the perioperative setting, patient safety initiatives will fail.²⁵ Changes in the culture of safety require a systematic approach.²⁶ The Comprehensive Unit-Based Safety Program (CUSP) was developed by the Johns Hopkins Medicine Quality and Safety Research Group and the Center for Innovation in Quality Patient Care and has been widely used to foster safe work environments.²⁷ Hospitals can easily apply this program to perioperative settings. In the six-stage process, organizations —

• Complete a culture survey
• Provide safety education
• Identify safety issues
• Handle issues
• Make improvements
• Share stories

In CUSP, everyone who provides care on a unit completes a safety culture survey, which is analyzed, and feedback is provided.²⁸ (A survey with adequate reliability and validity should be used; a number of surveys are available, one specifically for ORs.^13,29-33 Next, staff are educated about the science of safety through presentations, videos, and simulations. The staff then identify safety issues, which are communicated to the safety committee, leaders, and executives. If urgent problems exist, action is taken immediately. The safety committee discusses the issues and prioritizes them with senior executives. After the issues are prioritized, the committee identifies projects and assigns a leader for each. The leader of the project forms a team, which develops a plan to address the issues and evaluates outcomes through a quality improvement approach, Plan-Do-Study-Act.³⁴ (See http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Plan-Do-Study-Act+%28PDSA%29+Worksheet.htm.) Then the lessons learned are shared through “stories,” brief reports about the safety problem, the plan to solve it, and the outcomes. The culture survey is then repeated to evaluate the change in safety culture, and the results are compared to the baseline scores and external benchmarks.

Nurses have an essential role in creating a culture of safety. Nurse executives are responsible for designing, coordinating, and leading these efforts. Guiding principles outlined by the American Organization of Nurse Executives include leading culture change, providing shared leadership, building external partnerships, and developing leadership competencies.³⁵ Resources to foster the transition to a safe perioperative culture are available through the IHI and AORN Patient Safety First. Building this culture of safety requires a fundamental change in the healthcare work environment.

A major concern for healthcare leaders, patient safety in the OR is a fundamental component of practice for perioperative nurses as well as an interdisciplinary responsibility. The OR is replete with error-prone processes. The CUSP approach provides practical steps to build a culture of safety. Using standardized safety culture surveys will inform leadership of the baseline assessment of the culture of safety and help evaluate progress in building that culture.

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