Authors (including presenting author) :
Fung MY (1), Shen HM(1), Law WC(1)
Affiliation :
(1) Operating Theatre, Yan Chai Hospital
Introduction :
A near miss incident happened on 11/8/2021: patient having 'left' total knee replacement with a 'right' side implant opened to the sterile field. It was discovered and stopped by the surgeon before inserting to the patient body. This incident hold a red flag to peri-operative team for the risk of wrong side implant of the operation involving laterality, especially the high volume total joint replacement surgeries in our hospital. The peri-operative orthopedic team took prompt action to carry out strategy to mitigate the potential risk in a way forwards to a safe patient peri-operative journey.
Objectives :
1. to identify the underlying causes of the risk
2. to establish a sustainable implant verification procedure at the critical moment throughout the operation
3. to modify the environment and make use of tool to facilitate a correct implant's checking
4. to encourage a speak up culture and a two-way communication skill in operating theatre
Methodology :
A comprehensive root cause analysis was carried out with the following findings: 1) new staff were not familiar with existing implants' allocation and one-way communication was being used; 2) no IT nor manual tool as a reminder of the correctness of the operating side throughout the operation; 3) no standardized protocol for implant verification procedure; 4) implants of different sides were placed in the same cabinet; 5) no effective communication system to ensure a safe checking process in place.
Based on the identified contributing factors, the peri-operative orthopedic team make change to the existing checking as below using the PDCA cycle.
1. Material: use an 'Alert card' which indicates the operating side of the implant by posting up onto the whiteboard after “time out’
2. Method: implement an 'implant checkpoint' for implant verification with standard working protocol before delivering the implants to the sterile field.
3. System: identify 'designated persons' for checking the implants, allow time and minimize distraction during checking process. Use ‘Read-back’ strategy to clarify the side and size of the implants in each checking
4. Environment:adhere a 'big cross label' to the implant’s cabinets for implants of un-operative side at the beginning of the operation. This minimizes chance of getting incorrect implants.
5. Staff training: enhance the communication skill by using open end question to confirm laterality with surgeon and 'speak up' for any uncertainty
Result & Outcome :
A two-week trial with positive feedbacks from nurses and no incident related to wrong side implants has been happened. Now, the peri-operative orthopedic team has adapted this change to a standardized approach in implant verification procedure for all the total joint replacement operations. This mitigation project greatly promotes collaboration between surgeon and nurses to enhance a safe and effective surgery.
