National Patient Safety Goals for 2007 have been established by the Joint Commission on Accreditation of Health Care Organizations. The goals for ambulatory care/office-based surgery titled “National Patient Safety Goals” are promulgated to improve patient safety in settings including oral and maxillofacial surgical facilities. Some, but not all, of these goals are attached below for your assessment. The entire document is available on the Joint Commission Web site and quotations below are from the document.1
The ambulatory care/office-based surgery goals are an extension of national patient safety goals developed for the hospital setting that are designed to save tens of thousands of lives per year through the prevention of medical errors and promote an environment of patient safety. A Patient Safety Consortium (PSC) of more than 130 hospitals has been developed to create an environment and culture of patient safety to prevent medical errors and reduce avoidable patient injury.
Oral and maxillofacial surgeons have an opportunity to review these goals and incorporate them into practice. Patient safety concerns are known to the public to be a serious problem at the hospital level. Medication errors are believed to cause 7,000 deaths per year in American hospitals, while adverse drug events left unrecognized or improperly treated might result in more than 700,000 adverse events.2 While the impact of lapses in patient safety are not quantified in the oral and maxillofacial surgery setting, our specialty has the opportunity and need to proactively incorporate these ideas into practice and learn from the progress of our hospital colleagues.
These goals as applied to the ambulatory care/office-based oral and maxillofacial surgery setting can be divided into those that address:
1.Patient identification/surgical site identification
2.Communication
3.Medication safety
4.Reducing the risk of fire
5.Reducing the risk of infection (addressed in a previous JOMS editorial3) 6.Involving patients in patient safety issues
Patient Identification/Surgical Site Identification
Improve the accuracy of patient identification.1
In a busy office setting, patient identification preferably checked via 2 sources is necessary to prevent wrong site or wrong procedure errors. Wrong site surgery remains a primary risk management issue in oral and maxillofacial surgery practice. In the operating room, marking the site with the patient awake is a commonly used method to prevent wrong site surgery. Variation on this idea can be considered for such common procedures as exodontia and implant placement. JCAHO recommends “operative tooth names on documentation” or marking the operative site on radiographs or diagrams.4 Also “the pause” has become a common hospital operating room procedure where the patient name, identification information, site and procedure are confirmed just prior to initiating the opening incision.
Communication
Improve the effectiveness of communication among caregivers.1
For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and “read-back” the complete order or test result. Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.1
In the oral and maxillofacial surgery setting, accurately handing off information between the surgeon and staff and accurately transmitting it to relevant parties creates several potential sites for error. Surgeons should develop a training program and ongoing assessment to ensure that such useful procedures as “read back,” standardized abbreviations and symbols, and timeliness of communication are continuously implemented.
Medication Safety
Improve the safety of using medications.1
Standardize and limit the number of drug concentrations used by the organization.1
Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field. Accurately and completely reconcile medications across the continuum of care. There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization. A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility.1
Using common dilutional procedures for drugs such as Versed (Roche, Nutley, NJ), especially when there are multiple practitioners will promote safety. Inadvertent interchange of similar drugs can be a problem in the oral and maxillofacial setting. Separating drugs that might look similar, except for the label, such as succinylcholine and fentanyl, will help prevent medication error. Limiting the number of drugs used to simplify and standardize the process for the surgical team will help prevent error. If a new drug, or new drug concentration is used, be sure the entire team is aware of the change and implementing it flawlessly. Labels should be prepared on every medication by the individual preparing the medication for use.
Obtaining a complete list of patient medications is an onerous but necessary task. Communicating an updated list of medications to the referring physician should be a task for the prescribing oral and maxillofacial surgeon
Prevent Fires
Reduce the risk of surgical fires.1
Educate staff, including operating licensed independent practitioners and anesthesia providers, on how to control heat sources and manage fuels with enough time for patient preparation, and establish guidelines to minimize oxygen concentration under drapes.1
Having experienced 2 surgical fires in my career, I am certain that my knowledge of this potential was enhanced by these events. Every hospital is charged with developing education and protocols for surgical fires. A good surgical fire prevention poster can be downloaded to educate your surgical team. While such protocols can be adapted for the oral and maxillofacial surgery setting, the characteristics peculiar to our ambulatory surgical environment can create special needs. Surgery in the upper airway, the flammability of resins and volatile liquids such as methylmethacylate monomer, and the high concentration of oxygen in the surgical site/airway make our needs in fire prevention unique. Oral and maxillofacial surgery would benefit from the development of a fire prevention program directed towards our special needs.
Involve Patients in Your Safety Plan
Encourage patients’ active involvement in their own care as a patient safety strategy.1
Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.1
Our patients have silent concerns that they do not bring up for a variety of reasons. They should be encouraged to voice their safety concerns. Whether raised out of limited knowledge or anxiety, perception is reality when a patient concern is left unaddressed. By encouraging patients to voice their concerns, you may be able to simply allay their fears or you may discover a new path to improved patient safety procedures in your office.
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