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Want to Improve Safety? Ask Questions
EDITORIAL
Want to Improve Safety? Ask Questions PATRICIA C. SEIFERT, RN, MSN, CNOR, CRNFA, FAAN, EDITOR-IN-CHIEF
Curiosity killed the cat; but satisfaction brought her back.
N
umerous organizations are encouraging patients and their family members to question caregivers. The Agency for Healthcare Research and Quality (AHRQ) says “Questions Are the Answer”;1 the Joint Commission encourages consumers to “Speak Up”;2 and AORN promotes patient and caregiver interaction as part of its Correct Site Surgery Tool Kit.3 The aim of such questioning is to improve safety and reduce the number of health care-related errors by having patients become actively involved and informed members of the team, thus promoting their own safe care. Perioperative nurses—and all caregivers—also can influence patient care by asking questions. The questions may be generated by changes in a practice or policy that alert the clinician to the potential for an error, or they may be associated with questions that patients themselves ask. For example, in reviewing questions that the AHRQ encourages patients to ask before surgery,4 I realized there are safety-related questions that a nurse can ask as part of an ongoing patient assessment. The AHRQ questions (below, in bold text) are followed by related questions that perioperative nurses can ask of themselves. These questions hone in on a patient’s specific needs and promote a surgical environment that positively influences the level of safety. • Why do I need surgery? • What is the patient’s pathophysiology? • How will it affect the operative/ interventional options?
© AORN, Inc, 2008
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What kind of surgery do I need? • What is the rationale for this particular procedure? Are there alternatives to surgery? • Is an interventional/minimally invasive procedure feasible for this patient? How much will the surgery cost? • Am I making judicious and costeffective use of the supplies for this procedure? What are the benefits and risks of the surgery? • What are the benefits and risks of the surgeon’s interventions or my nursing Perioperative nurses interventions? • What risk factors and their patients for error exist? What if I don’t have can influence the the surgery? • What if the surgery patient’s care by is cancelled? • How do I notify the asking the right patient’s family? Where can I get a secquestions. ond opinion? • What are other surgical options for this patient? What kind of anesthesia will I need? • In what anesthesia class is the patient? • What risks are associated with the anesthesia? How much experience do you have doing this surgery? • Do my teammates and I have the requisite skill sets and competencies to participate in this procedure? Where will the surgery be performed? • Which OR, interventional suite, or procedure room will we use? NOVEMBER 2008, VOL 88, NO 5 • AORN JOURNAL • 707
NOVEMBER 2008, VOL 88, NO 5
Nurses can help prevent “never events” by questioning the surgeon, anesthesia care provider, fellow RN, surgical technologist, or anyone else involved in the care of the patient.
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How long will I be in the hospital? • How can we maximize the patient’s postoperative course during the intraoperative period? Another situation in which questioning can be crucial is during the preprocedure “time out”—the pause during which all team members must agree on the patient, procedure, site, and position. Any team member who questions the procedure, the site, or the side is urged to voice his or her concern; discrepancies must be resolved before the procedure continues. Questioning also influences patient safety in other ways. Among the AHRQ’s Patient Safety Primers is one on the subject of “never events.”5 Never events were introduced by the National Quality Forum and refer to medical errors that should never occur and usually are preventable.5,6 Never events include • surgery on the wrong body part, • surgery on the wrong patient, • the wrong procedure performed on a patient, and • unintended retention of a foreign object. Each of these events can be prevented by asking a pertinent question. For example, “Doctor, our count is incorrect. I think there’s a sponge in the patient’s belly; can we look?” Or, “Mr Smith told me his left knee was bothering him . . . not his right knee; can we ask him again?” Or, “This is Mrs JANE Jones, not Mrs NANCY Jones; which Mrs Jones is our patient?” In a 2008 report from the Minnesota Department of Health, investigators found that 60% of the 125 reported never events were surgical. Re-
708 • AORN JOURNAL
Editorial
tained objects accounted for 25%, wrong site surgery for 24%, wrong procedure surgery for 10%, and other surgical events for 1%.7 Prevention of these events can be strongly influenced by nursing actions, including raising doubt; asking for clarification; and questioning the surgeon, anesthesia care provider, fellow RN, surgical technologist, or anyone else involved in the care of the patient. “Perioperative Nurses: Influencing the Future of Safe Patient Care” is the theme for AORN’s 2008 Perioperative Nurse Week. This influence can be exercised in many ways. One of the simplest and most effective is to verbalize that something does not seem right. Motivate novices to articulate concerns, encourage experts to scrutinize assumptions, and promote a workplace that respects curiosity and inquiry. The question not asked may lead to an error not prevented.
REFERENCES 1. Questions Are the Answer. Agency for Healthcare Research and Quality. http://www.ahrq.gov/ques tionsaretheanswer. Accessed September 24, 2008. 2. Speak Up. The Joint Commission. http://www .jointcommission.org/PatientSafety/SpeakUp. Accessed. September 24, 2008. 3. Download the Correct Site Surgery Tool Kit. AORN, Inc. http://www.aorn.org/PracticeResources /ToolKits/CorrectSiteSurgeryToolKit/Download TheCorrectSiteSurgeryToolKit. Accessed September 24, 2008. 4. Questions Are the Answer: Planning for Surgery. Agency for Healthcare Research and Quality. http:// www.ahrq.gov/questionsaretheanswer/level3col_1 .asp?nav=3colNav04&content=04_0_planning. Accessed September 24, 2008. 5. Patient Safety Primer: Never Events. AHRQ PSNet. http://psnet.ahrq.gov/primer.aspx?primer ID=3. Accessed September 24, 2008. 6. NQF-endorsedTM serious reportable events in healthcare: 2006 update. http://www.qualityforum .org/pdf/news/txSREReportAppeals10-15-06.pdf. Accessed September 24, 2008. 7. Consumer Guide to Adverse Health Events. St Paul, MN: Minnesota Department of Health; January 2008. http://www.health.state.mn.us/patientsafety /publications/consumerguide.pdf. Accessed September 24, 2008. PATRICIA C. SEIFERT RN, MSN, CNOR, CRNFA, FAAN EDITOR-IN-CHIEF
Want to Improve Safety? Ask Questions PATRICIA C. SEIFERT, RN, MSN, CNOR, CRNFA, FAAN, EDITOR-IN-CHIEF
Curiosity killed the cat; but satisfaction brought her back.
N
umerous organizations are encouraging patients and their family members to question caregivers. The Agency for Healthcare Research and Quality (AHRQ) says “Questions Are the Answer”;1 the Joint Commission encourages consumers to “Speak Up”;2 and AORN promotes patient and caregiver interaction as part of its Correct Site Surgery Tool Kit.3 The aim of such questioning is to improve safety and reduce the number of health care-related errors by having patients become actively involved and informed members of the team, thus promoting their own safe care. Perioperative nurses—and all caregivers—also can influence patient care by asking questions. The questions may be generated by changes in a practice or policy that alert the clinician to the potential for an error, or they may be associated with questions that patients themselves ask. For example, in reviewing questions that the AHRQ encourages patients to ask before surgery,4 I realized there are safety-related questions that a nurse can ask as part of an ongoing patient assessment. The AHRQ questions (below, in bold text) are followed by related questions that perioperative nurses can ask of themselves. These questions hone in on a patient’s specific needs and promote a surgical environment that positively influences the level of safety. • Why do I need surgery? • What is the patient’s pathophysiology? • How will it affect the operative/ interventional options?
© AORN, Inc, 2008
• •
•
•
•
•
•
•
•
What kind of surgery do I need? • What is the rationale for this particular procedure? Are there alternatives to surgery? • Is an interventional/minimally invasive procedure feasible for this patient? How much will the surgery cost? • Am I making judicious and costeffective use of the supplies for this procedure? What are the benefits and risks of the surgery? • What are the benefits and risks of the surgeon’s interventions or my nursing Perioperative nurses interventions? • What risk factors and their patients for error exist? What if I don’t have can influence the the surgery? • What if the surgery patient’s care by is cancelled? • How do I notify the asking the right patient’s family? Where can I get a secquestions. ond opinion? • What are other surgical options for this patient? What kind of anesthesia will I need? • In what anesthesia class is the patient? • What risks are associated with the anesthesia? How much experience do you have doing this surgery? • Do my teammates and I have the requisite skill sets and competencies to participate in this procedure? Where will the surgery be performed? • Which OR, interventional suite, or procedure room will we use? NOVEMBER 2008, VOL 88, NO 5 • AORN JOURNAL • 707
NOVEMBER 2008, VOL 88, NO 5
Nurses can help prevent “never events” by questioning the surgeon, anesthesia care provider, fellow RN, surgical technologist, or anyone else involved in the care of the patient.
•
How long will I be in the hospital? • How can we maximize the patient’s postoperative course during the intraoperative period? Another situation in which questioning can be crucial is during the preprocedure “time out”—the pause during which all team members must agree on the patient, procedure, site, and position. Any team member who questions the procedure, the site, or the side is urged to voice his or her concern; discrepancies must be resolved before the procedure continues. Questioning also influences patient safety in other ways. Among the AHRQ’s Patient Safety Primers is one on the subject of “never events.”5 Never events were introduced by the National Quality Forum and refer to medical errors that should never occur and usually are preventable.5,6 Never events include • surgery on the wrong body part, • surgery on the wrong patient, • the wrong procedure performed on a patient, and • unintended retention of a foreign object. Each of these events can be prevented by asking a pertinent question. For example, “Doctor, our count is incorrect. I think there’s a sponge in the patient’s belly; can we look?” Or, “Mr Smith told me his left knee was bothering him . . . not his right knee; can we ask him again?” Or, “This is Mrs JANE Jones, not Mrs NANCY Jones; which Mrs Jones is our patient?” In a 2008 report from the Minnesota Department of Health, investigators found that 60% of the 125 reported never events were surgical. Re-
708 • AORN JOURNAL
Editorial
tained objects accounted for 25%, wrong site surgery for 24%, wrong procedure surgery for 10%, and other surgical events for 1%.7 Prevention of these events can be strongly influenced by nursing actions, including raising doubt; asking for clarification; and questioning the surgeon, anesthesia care provider, fellow RN, surgical technologist, or anyone else involved in the care of the patient. “Perioperative Nurses: Influencing the Future of Safe Patient Care” is the theme for AORN’s 2008 Perioperative Nurse Week. This influence can be exercised in many ways. One of the simplest and most effective is to verbalize that something does not seem right. Motivate novices to articulate concerns, encourage experts to scrutinize assumptions, and promote a workplace that respects curiosity and inquiry. The question not asked may lead to an error not prevented.
REFERENCES 1. Questions Are the Answer. Agency for Healthcare Research and Quality. http://www.ahrq.gov/ques tionsaretheanswer. Accessed September 24, 2008. 2. Speak Up. The Joint Commission. http://www .jointcommission.org/PatientSafety/SpeakUp. Accessed. September 24, 2008. 3. Download the Correct Site Surgery Tool Kit. AORN, Inc. http://www.aorn.org/PracticeResources /ToolKits/CorrectSiteSurgeryToolKit/Download TheCorrectSiteSurgeryToolKit. Accessed September 24, 2008. 4. Questions Are the Answer: Planning for Surgery. Agency for Healthcare Research and Quality. http:// www.ahrq.gov/questionsaretheanswer/level3col_1 .asp?nav=3colNav04&content=04_0_planning. Accessed September 24, 2008. 5. Patient Safety Primer: Never Events. AHRQ PSNet. http://psnet.ahrq.gov/primer.aspx?primer ID=3. Accessed September 24, 2008. 6. NQF-endorsedTM serious reportable events in healthcare: 2006 update. http://www.qualityforum .org/pdf/news/txSREReportAppeals10-15-06.pdf. Accessed September 24, 2008. 7. Consumer Guide to Adverse Health Events. St Paul, MN: Minnesota Department of Health; January 2008. http://www.health.state.mn.us/patientsafety /publications/consumerguide.pdf. Accessed September 24, 2008. PATRICIA C. SEIFERT RN, MSN, CNOR, CRNFA, FAAN EDITOR-IN-CHIEF