OR Connection Magazine - Volume 6 Issue 2

CAUTI
CULPRITS
Nab the Suspects
In Search
of the BEST
Pink Glove
Dancers!
Page 98
Crew Resource
Management
in the OR
The
Aligning practice with policy to improve patient care
FREE CE!
Victoria
Nahum
A Mother Turns
Tragedy into a
Crusade for
Patient Safety
ACOs
A Flexible
Approach
Volume 6, Issue 2
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116 The ORConnection
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Remedy are registered trademark of Medline
Industries, Inc.
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Editor
Sue M
Senio
Carla E
Creat
Michae
Clinica
Jayne
Lorri D
Margar
CWOC
Rhond
Anita G
Kimber
Rebec
Carla N
Claudia
Megan
Angel T
Periop
Garry C
Norma
Evange
Spivey
Linda G
Associ
Nurses
Darvina
Gwinne
Vivienn
Anahei
Colleen
Hospit
Juliean
South
Susan
St. Luk
Susan
UNC H
Jo Que
Provide
Washin
Eleono
The Mo
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Content Key
We've coded the articles and information in this magazine to indicate which patient
care initiatives they pertain to. Throughout the publication, when you see these icons
you'll know immediately that the subject matter on that page relates to one or more of
the following national initiatives:
IHI's Improvement Map
Joint Commission 2009 National Patient Safety Goals
Surgical Care Improvement Project (SCIP)
We've tried to include content that clarifies the initiatives or gives you ideas and tools
for implementing their recommendations. For a summary of each of the initiatives,
see pages 6 and 7.
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Joint Commission - Wrong Site Surgery Solutions Forms & Tools
Aligning practice with policy to improve patient care 115
PATIENT SAFETY
14 Reduce Medical Errors, Healthcare-Acquired Conditions
17 Joint Commission Center for Transforming Healthcare Aims
to Reduce the Risk of Wrong Site Surgery
20 Patient Safety News
24 Joint Commission CAUTI Book Now Available
26 Unlikely Heroes
43 Surgical Site Infections
62 CAUTI Prevention: Cracking the Case
76 Preparing Your Hospital for Successful Quality Improvement
82 ASGE, SHEA Issue New Guidelines on Reprocessing Flexible
Gastrointestinal Endoscopes
OR ISSUES
30 Arrogant, Abusive and Disruptive And a Doctor!
40 Crew Resource Management in Action at Unity Hospital
46 Building a Culture of Operating Room Safety
SPECIAL FEATURES
8 Transforming the Health Care Delivery System
10 A Flexible Approach to the ACO Model
22 2011 Nursing Leadership Priorities: The CNOs Perspective
38 Cleared for Takeoff?
54 Aurora Aces an Open Heart Case
58 The Basics of Todays Surgical Mesh and What the Future Holds
86 Patient Safety Mystery Message
94 In Celebration of Breast Cancer Awareness: Touring Art Exhibit
98 National Contest Seeks Best Pink Glove Dance Video
CARING FOR YOURSELF
88 Time Management
100 Seven Tips for Cleaning Fruits and Vegetables
102 Recipe: Baby Blue Salad
FORMS & TOOLS
105 One and Only Campaign
107 Occupational Sharps Injury Log Addendum
108 Risk for Bacterial Meningitis
110 Your 5 Moments for Hand Hygiene
111 10 Patient Safety Tips for Hospitals
113 Main Causes of Wrong Site Surgeries
115 Solutions for Reducing the Risk of Wrong Site Surgery
Editor
Sue MacInnes, RD, LD
Senior Writer
Carla Esser Lake
Creative Director
Michael Gotti
Clinical Team
Jayne Barkman, BSN, RN, CNOR
Lorri Downs, RN, BSN, MS, CIC
Margaret Falconio-West, BSN, RN, APN/CNS,
CWOCN, DAPWCA
Rhonda J. Frick, RN, CNOR
Anita Gill, RN
Kimberly Haines, RN, Certified OR Nurse
Rebecca McPherson RN, MSN
Carla Nitz, BSN, RN
Claudia Sanders, RN, CFA
Megan Shramm, RN, CNOR, RNFA
Angel Trichak, RN, BSN, CNOR
Perioperative Advisory Board
Garry Crawford, RN, CNOR, MS
Norman Regional Health System, Oklahoma
Evangeline Dennis, RN, BSN, CNOR, CMLSO
Spivey Station Surgery Center, Georgia
Linda Groah, MSN, RN, CNOR, NEA-BD, FAAN
Association of periOperative Registered
Nurses, Colorado
Darvina L. Heichemer, BSN, AORN
Gwinnett Medical Center Duluth, Georgia
Vivienne P. Kaplan, RN
Anaheim Regional Medical Center, California
Colleen Mattioni, MBA, RN, CNOR
Hospital of the University of Pennsylvania
Julieann McIntyre, RN, MSN, CNOR
South Shore Hospital, Massachusetts
Susan A. Miller, RN, MSN, CNOR
St. Lukes Hospital, Missouri
Susan S. Phillips, RN, MSH, CNOR
UNC Hospitals, North Carolina
Jo Quetsch, MA, RN, NE-BC
Providence Sacred Heart Medical Center,
Washington
Eleonora Shapiro, BSN, MHA, CNOR
The Mount Sinai Medical Center, New York
About Medline
Medline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospitals, extended
care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than 800 dedicated
sales representatives nationwide to support its broad product line and cost management services.
2011 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
Page 30
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OR17_mag_8.17.11.2_Layout 1 8/18/11 4:58 AM Page 3
As I write this, it is the week before the Medline-hosted annual
Prevention Above All conference. Preparations are being final-
ized, materials are being pulled together, and I have been on the
phone with each of the presenters going over the flow of the
meeting, letting them know who will be attending and reviewing
the key messaging for each segment. Despite all the chaos, I
feel fortunate. I have the privilege of speaking to some of the
most amazing leaders in healthcare today. But these conversa-
tions turn into heartache when talking with family members who
have faced unfathomable anguish due to medical errors. Its
amazing to think you could lose a child and turn that bitterness
into something positive. That is what Victoria Nahum (on the
cover) did when she lost her son to an infection, and then poured
all her energies into spearheading the Safe Care Campaign. Or
Sorrel King, who lost her 2-year-old daughter to a medical error,
and then created a patient safety program at the very hospital
where her daughter died.
These are just a couple of examples of the real stories and the
real people who will be part of this conference. Maybe you can
understand why I got so passionate about this conference that
I included the speaker list and a broad overview for you in this
edition of The OR Connection. I know there is not a lot about
this conference that is specific to the OR. But I also know that
you are a key player in your organization and it cant hurt to let
you know what is going on outside the OR suite. Most of the
material from the Prevention Above All conference will be
videotaped, so I urge you to go on Medline University and listen
to the parts you are most interested in.
And, if you arent into watching video clips, Id like to suggest
some good reading material. Josies Story, an absolutely amazing
story about a mother, a child and the journey to recovery. I gave
this book (over the summer) to my 20-year-old daughter, and
she did not put it down until she was finished. Another great
book is Between a Rock and a Hard Place by Aron Ralston, who
is also speaking at the conference. He was the inspiration for the
Academy Award-nominated film, 127 Hours. I spoke to him
last Friday night, and he said that the happiest moment of his
life was when he cut off his arm. I had a hard time processing this
until he explained. Aron had a life-changing moment in the
canyons of Utah. His love for his family and desire to live inspired
him to sever his arm to save his own life.
So, what does all this have to do with you, with the OR, or with
your career?
If the articles in this issue of The OR Connection inspire you,
make you a better caregiver, or help you make the right deci-
sions, then we have accomplished a lot! One person can make
a difference and that one person can be you!
All the best to you!!!
Sue
P.S. Check out page 98 for more information on how you can
support breast cancer awareness at your hospital by being a
part of the Pink Glove Dance competition.
4 The ORConnection
The OR Connection
Letter from the Editor
About the cover
When her son, Josh (left), died at 27 from a hospital-acquired infection,
Victoria Nahum channeled her emotions into forming the Safe Care
Campaign, an organization dedicated to infection prevention, in hopes
that others be spared similar family tragedy.
When Medline builds your custom cath lab
kits, we help you to design a kit that best
ts your practice. With our new line of uid
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2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
6 The ORConnection
Three Important National Initiatives
for Improving Patient Care
Achieving better outcomes starts with an understanding of current
patient-care initiatives. Heres what you need to know about national
projects and policies that are driving changes in care.
Origin: Launched by the Institute for Healthcare Improvement (IHI) in January 2009
Purpose: To help hospitals improve patient care by focusing on an essential set of processes needed to
achieve the highest levels of performance in areas that matter most to patients.
Hospitals sign up through IHI and can choose to implement some or all of the recommended interventions.
IHI provides how-to guides and tools for all participating hospitals.
The IHI Improvement Map covers the entire landscape of outstanding hospital care to help hospitals make sense of countless
requirements and focus on high-leverage changes to transform care. There are 73 processes grouped into three domains:
leadership and management, patient care and processes to support care.
Origin: The development and updating of the National Patient Safety Goals (NPSGs)
is overseen by the Patient Safety Advisory Group.
Purpose: The NPSGs were established in 2002 to help accredited organizations address specific
areas of concern regarding patient safety.
Joint Commission-accredited organizations are evaluated for compliance with these goals. The Joint Commission offers
guidance to help organizations meet goal requirements.
Origin: Initiated in 2003 as a national partnership. Steering committee includes the following
organizations: CDC, CMS, ACS, AHRQ, AHA, ASA, AORN, VA, IHI and the
Joint Commission
Purpose: To improve patient safety by reducing postoperative complications
Goal: To reduce nationally by 25 percent the incidence of surgical complications by 2010
SCIP aims to reduce surgical complications in three target areas. Participating hospitals collect data on specific process and
outcome measures. The SCIP committee believes it could prevent 13,000 perioperative deaths and up to 300,000 surgical
complications annually (just in Medicare patients) by getting performance up to benchmark levels.
IHI Improvement Map
1
Joint Commission 2011-2012 National Patient Safety Goals
2
3

IHI Improvement Map: 73 Processes to Transform Hospital Care
Surgical Care Improvement Project (SCIP): Target Areas
Joint Commission 2011-2012 National Patient Safety Goals
Patient Safety
Effective January 1, 2011:
Improve the accuracy of patient identification.
Improve the effectiveness of communication
among caregivers.
Improve the safety of using medications.
Reduce the risk of healthcare-associated
infections.
Reduce the risk of patient harm resulting
from falls.
Prevent healthcare-associated pressure
ulcers (decubitus ulcers).
The organization identifies safety risks inherent
in its patient population.
Universal Protocol for Preventing Wrong Site,
Wrong Procedure, and Wrong Person Surgery.
- Conduct a pre-procedure verification process.
- Mark the procedure site.
- A time-out is performed before the procedure.
Effective January 1, 2012:
Implement evidence-based practices to prevent in-
dwelling catheter-associated urinary tract infections
(CAUTI).
To learn more about National Patient Safety Goals, go to www.jointcommission.org.
To learn more about the IHI Improvement Map and the 73 processes to transform hospital care, go to www.ihi.org/imap/tool
1. Surgical infections
Antibiotics, blood sugar control, hair removal, perioperative
temperature management
Remove urinary catheter on Post Operative Day (POD) 1 or 2
2. Perioperative cardiac events
Use of perioperative beta-blockers
3. Venous thromboembolism
Use of appropriate prophylaxis
The Improvement Map aims to help:
Make care safer
Make patient care transitions smoother
Lead improvement efforts effectively
Reduce costs and increase quality
1. Adverse Drug Events
2. Catheter-Associated Urinary Tract
Infections (CAUTIs)
3. Central Line-Associated Blood-
stream Infections (CLABSIs)
4. Injuries from Falls and Immobility
5. Obstetrical Adverse Events
6. Pressure Ulcers
7. Surgical Site Infections
8. Venous Thromboembolism
9. Ventilator-Associated Pneumonia
Helping hospitals improve in nine core focus
areas identified by Partnership for Patients
Visit www.qualitynet.org
Transforming
the Health Care
Delivery System
by Teresa Nguyen Clark, MPH, MBA
8 The ORConnection
Special Feature

The Secretary shall establish a hospital value-based purchasing program under which
value-based incentive payments are made in a scal year to hospitals that meet the
performance standards...
H.R. 3590 Patient Protection and Affordable Care Act 2010
Title III, Subtitle A, Part I
What is hospital value-based purchasing?
Much talk exists in the media about value-based purchasing. Is
it legislation? Is it a change in payment? Is it a new focus? It is
all those things - legislation, payment, and focus. But what is it
to you?
The recently enacted health care reform law H.R. 3590
Patient Protection and Affordable Care Act 2010 established
a hospital value-based purchasing (VBP) program, which is a
new payment system that will be implemented for the Medicare
program by the Centers for Medicare & Medicaid Services
(CMS) starting in October 2012. Under the Medicare VBP pro-
gram, hospitals that do not surpass CMS-mandated perform-
ance targets will be subject to reimbursement penalties.
The Medicare VBP program initially focuses on ve clinical con-
ditions:
Acute myocardial infarction (AMI)
Heart failure (HF)
Pneumonia (PN)
Surgeries, as measured by the Surgical Care
Improvement Project (SCIP)
Healthcare-associated infections (HAI)
In addition to these ve clinical conditions, the Medicare VBP
program also focuses on Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS), which is the
patients perspective on quality.
How is any of this different than today?
Today, Medicare lets your hospital know ahead of time what
the performance target for payment will be. Knowing this ahead
of time, you can anticipate what your future reimbursements
may be, based upon your performance relative to the pre-
dened Medicare target. Then if you meet the performance
targets, you share in the savings with other hospitals.
Come 2012, in a hospital value-based purchasing environment,
you no longer know what the performance target will be ahead
of time. That is, Medicare will no longer pre-dene the target
before the performance period. Instead, Medicare will set the
target after the performance period, with the performance tar-
get set at the national level.
This essentially means your hospital will now be in a national
competition for Medicare dollars, regardless of hospital char-
acteristics, such as size and teaching status. This also means
that going into a performance period, your hospital no longer
knows what the Medicare performance target will be.
How will this change what I do today?
Although October 2012 seems far away, Medicare will be start-
ing to look at your baseline performance this summer. This
leaves you little time to make changes that ready you for work-
ing in a value-based purchasing environment.
In addition to the timing of changes, value-based purchasing
will also affect your focus. Medicare has focused payment on
clinical conditions and it will continue to do so under VBP.
However, under VBP Medicare will now also focus on the
patient experience of care, as measured by the HCAHPS. The
HCAHPS will shift your focus from clinician and disease
process-centric to patient-centered.
Okay then - Where do I start?
With the upcoming changes, there are two places to start
looking:
1. How do you compare to the national market,
regardless of hospital characteristics?
2. From whose perspective is your patient experience
of care model based upon? Clinicians? Patients?
Title III focus on Medicare VBP dramatically alters the health
care landscape. If not prepared, your hospital, clinicians, and
leaders will be left in a precarious position when the Medicare
VBP payment effects begin October 2012.
Teresa Nguyen Clark, MPH, MBA, is vice president of clinical
business strategy and delivery for VHA, Inc., where she is respon-
sible for developing business and implementation strategies for
VHAs clinical performance team to enhance the companys efforts
to drive sustainable quality improvement with its members. Before
joining VHA in 2007, Teresa was the special assistant to the Cen-
ters for Medicare and Medicaid Services (CMS) chief medical of-
cer and the director of the Ofce of Clinical Standards and Quality.
A Flexible Approach
to the ACO Model
Accountable care organizations (ACOs) have become a hot topic in healthcare reform over the
past several months as hospitals and healthcare professionals scramble to make sense of this
newly proposed care model.
As one of the nations foremost health industry analysts, specializing in corporate strategy, trend
analysis, health policy and emerging technologies, Jeff Goldsmith, PhD, lecturer, consultant and
president of Health Futures, Inc., shares his vision of the ACO as a exible partnership between
health plans and providers.
Goldsmith suggests breaking the costs of health services into three categories:
1. Primary care: low-intensity health maintenance delivered by primary physicians
2. Unscheduled care: episodic diagnostic services delivered by ofce-based physicians
and unscheduled emergency services at hospitals
3. Specialty care: major clinical interventions such as comprehensive cancer care
10 The ORConnection
Special Feature
Primary care
Goldsmith proposes that the current primary care model is no
longer economically viable because the fee-based payments it
relies on have not grown as quickly as practice expenses.
Physicians have begun seeing more patients and increasing
income by more frequent use of lab testing and imaging. As a
result, primary care physicians are not spending as much time
with patients, and they run the risk of recommending testing
more for economic reasons than for medical ones.
To avoid this, Goldsmith supports the patient-centered medical
home model. The physician is leader of the medical home, and
much of the contact with patients is through phone calls and
email. Medical management and support services are provided
by advanced practice nurses and nurse educators. The goal is
to follow protocols and guidelines for how specic clinical risks
should be managed. Goldsmith says there is evidence that
more effective primary care focused on the patients specic
health risks such as diabetes, high blood pressure, and
asthma can reduce medical expenses downstream, and that
this model deserves a higher level of payment than traditional
fees because it offers a wider range of services.
Surviving and Thriving
Amidst Healthcare Reform
Top ve tips for hospitals
1. Run lean
2. Recognize risk is here
3. The place to start with population
health is inside your facility
4. Invest in physician leadership
and seek consensus on the
new care model
5. Markedly improve the family
experience, both during and
after care
- j.g.
The physician is leader
of the medical home...
Medical management
and support services are
provided by advanced
practice nurses and
nurse educators.
12 The ORConnection
Goldsmith believes the most efcient and cost-effective
approach to specialty care is delivered by groups of
specialists working together as a team using a well-
dened model of care.
Unscheduled care
Goldsmith suggests that the medical home model would
minimize unscheduled care with its focus on consultation on
demand through email or phone calls instead of requiring that
patients address all of their medical needs through an ofce visit.
Specialty care
Goldsmith believes the most efcient and cost-effective
approach to specialty care is delivered by groups of specialists
working together as a team using a well-dened model of care.
Many hospitals and health systems are already using this
approach with multidisciplinary centers of excellence focused
on cardiac or cancer services. Using this model, Goldsmith
suggests a single, severity-adjusted payment for all
pre-intervention diagnostics and testing, the intervention itself
(i.e., surgery or chemotherapy) and postintervention costs for
follow-up surveillance, rehabilitation and testing. The overall
result is better collaboration among providers and care that is in
the best interest of patients.
Reference
Goldsmith J. Accountable care organizations: the case for exible partnerships
between health plans and providers. Health Affairs. 2011; (30)1.
Jeff Goldsmith, PhD, is president of
Health Futures, Inc., and an associate
professor of public health sciences at
the University of Virginia. During the
1990s he lectured on health services
management and policy at the
Graduate School of Business at the
University of Chicago, the Wharton
School of Finance, Johns Hopkins
University, Washington University and
the University of California at Berke-
ley. Earlier in his career he served as national advisor for health-
care for Ernst and Young, providing strategy consultation to a
wide variety of healthcare systems and health plans. He earned
his doctorate in sociology from the University of Chicago in
1973. His areas of interest include biotechnology, health policy,
international health systems, and the future of health services.
To learn more, visit his website at www.healthfutures.net.
Medline University continues to build its curriculum
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From August 21-23, 2011, Chicago was the epicenter for the
nations healthcare community. That is when more than 200
healthcare leaders from around the country gathered to share
ideas and learn from the countrys foremost experts on reducing
medical errors and healthcare acquired conditions (HACs) at
the fourth annual Prevention Above All conference.
Clinical and quality leaders from hospitals, nursing homes,
surgery centers and other alternate sites heard from national
healthcare experts who offered insight and real-life solutions to:
Decreasing Risk by Avoiding Ineffective Practices
Implementing Innovative Practices in Preparation for
Value-Based Healthcare
Identifying Important Opportunities for 2011
A must-see!
Filmed presentations will be available for no charge beginning
September 15 at www.MedlineUniversity.com. And while youre
there, explore Medline University for more thought-provoking
healthcare-related videos and courses as well.
Featured speakers and their topics included:
Richard L. Clarke
DHA, FHFMA President and CEO,
Healthcare Financial Management
Association
The Value Imperative
Jeff Goldsmith
PhD, President, Health Futures, Inc.
Decisions on Payment Models in
Value-Based Healthcare; How
Accountable Care Organizations
Will Impact the Future
Prevention of Performance Loss Due to Lack
of Coordination
James Avery
MD, CMD, FACP, FCCP, FAAHPM
Senior Vice President, Chief Medical
Ofcer, Golden Living
Nursing Homes and Hospitals:
A Marriage Made in Heaven
Mark Chassin
MD, FACP, MPP, MPH, President,
The Joint Commission
"High Reliability in Health Care:
What is it and Why You Should Care
Prevention of Barriers to Patient-Centered Care
Victoria Nahum
Co-Founder and Executive
Director, Safe Care Campaign
Change One Thing, Change
Everything
Sorrel King
Author, Founder - Josie King
Foundation
Josie's Story: Family-Centered
Approaches to Patient Safety
Experts Discuss Real Ways to Reduce
Medical Errors, Healthcare-Acquired Conditions
14 The ORConnection

Prevention of Impediments to Intervention
and Integration
Candace Smith
MPA, RN, NEA- BC, SVP,
Chief Nursing Ofcer,
Clinical Program Consultant,
Medline Industries, Inc.
The Patient Experience:
Fundamentals from the Lens
of the CMO/CNO
Panel Discussion: Integrating Supply Chain and Clinical
Leadership to Improve Outcomes
Tom Lubotsky
Vice President Supply Chain,
Clinical Resource Management,
Advocate Health Care
Barbara Young
Director of Purchasing/Distribution
AtlantiCare Regional Health System
Prevention of the Lack of Accountability
Carolyn M. Clancy
MD, Director, Agency for Healthcare
Research and Quality (AHRQ)
Dr. Dale Bratzler
DO, MPH, University of Oklahoma
Health Sciences Center College
of Public Health
Healthcare-Associated Infections
and Public Accountability
Prevention of Theory and Practices
That Impact Innovation
Trent T. Haywood
MD, JD, Senior Vice President
of Clinical Performance and Chief
Medical Ofcer, VHA Inc.
Social Practice: Observation for
Understanding and Improving
Deborah Adler
Principal, Deborah Adler, LLC
Changing Behavior by Design
Chris McCarthy
Director, ILN, Innovation Specialist, IC
Kaiser Permanente's Big Idea:
The Infrastructure of Design
Implementation: Positive Outcomes in 2011
Darrell L. Dean
DO, MPH, Medical Director
of Performance Improvement
Floyd Medical Center,
Rome, GA
Getting to Zero with CAUTI
Prevention
Patient Safety
Experts Discuss Real Ways to Reduce
Medical Errors, Healthcare-Acquired Conditions
Panel: Getting to Zero with Pressure Ulcer Prevention
Beth L. Edwards
RN, BA Clinical Quality Specialist,
Jennie Edmundson Memorial Hospital,
Council Bluffs, IA
Debbie Lygren
RN, BS, RHIT, Nurse Consultant,
Peak Resources Inc.
Jackie Medland
RN, PhD, Chief Nurse Executive,
Provena St. Joseph Medical Center,
Joliet, IL
Martie Moore
RN, BSN, MAOM, CPHQ,
Chief Nursing Ofcer, Providence St.
Vincent Medical Center, Portland, OR
Fall Prevention Strategies That Work
Sara Atwell
RN, MHA, Chief Quality
and Patient Safety
Ofcer Oakwood Healthcare
System, Detroit, MI
Hand Hygiene; Pulling It All
Together and Making It Work
Lee Sacks, MD
Executive Vice President and Chief
Medical Ofcer Advocate Health Care,
Chicago, IL
Clinical Coordination: The Coordination
of Care through Alignment of Hospitals
with Physicians to Support Inpatient
and Ambulatory Care
Aron Ralston
Author, Between a Rock and
a Hard Place: Inspiration for
the Film 127 Hours
Making Decisions in the
Face of Adversity
16 The ORConnection
Video clips from the meeting will be available online after August 25, 2011.

Joint Commission Center for Transforming Healthcare
Aims to Reduce the Risk of Wrong Site Surgery
Health care professionals and patients all agree that wrong site surgery is a
serious and preventable adverse event that should never happen. Although
reporting is not mandatory in most states, some estimates put the national
incidence rate, which includes wrong patient, wrong procedure, wrong site,
and wrong side surgeries, as high as 40 per week.
Patient Safety
18 The ORConnection
Top 3 risk factors for wrong site surgery
1. Problems with scheduling and pre-op/holding processes
2. Ineffective communication and distractions in the
operating room
3. Time Out without full participation by all key people in
the operating room
Recognizing this as a critical patient safety issue,
eight U.S. hospitals and ambulatory surgical centers teamed
up with the Joint Commission Center for Transforming Health-
care to address the problem. The Center and the participating
organizations used methods such as Lean Six Sigma and
change management to discover the causes of and put a stop
to these preventable breakdowns in patient care.
The participating hospitals and ambulatory surgical centers
found that problems with scheduling and pre-op/holding
processes, as well as ineffective communication and distrac-
tions in the operating room contributed to increasing the risk of
wrong site surgery. In addition, a Time Out without full partici-
pation by all key people in the operating room was identied as
another contributing factor that increased risk.
These contributing factors vary by organization and by event.
This underscores the importance of understanding the specic
contributing factors that increase risk in each organization so
that appropriate solutions can be targeted to reduce the spe-
cic risks in that organizations processes.
By reinforcing quality and measurement, emphasizing a cul-
ture of safety, strengthening knowledge about wrong site sur-
gery, and improving consistency in surgical processes, the
eight participating health care organizations and the Center
found that opportunities for errors or defects could be reduced.
For example, addressing documentation and verification
issues in the pre-op/holding areas decreased defective cases
from a baseline of 52 percent to 19 percent. Defects are the
causes of and risks for wrong site surgery. In turn, the inci-
dence of cases containing more than one defect decreased
72 percent.
The focus on eliminating defects is important because a single
operative case has multiple opportunities for defects. When
there are multiple defects in a single case, it can further
increase the risk of an error reaching the patient. Additionally,
it was found that defective cases occurred more frequently
when more than one procedure was performed.
The eight hospitals and ambulatory surgical centers that vol-
unteered to address wrong site surgery as a critical patient
safety problem are:
AnMed Health, Anderson, South Carolina
Center for Health Ambulatory Surgery Center,
Peoria, Illinois
Holy Spirit Hospital, Camp Hill, Pennsylvania
La Veta Surgical Center, Orange, California
Lifespan-Rhode Island Hospital, Providence, Rhode Island
The Mount Sinai Medical Center, New York, New York
Seven Hills Surgery Center, Henderson, Nevada
Thomas Jefferson University Hospitals,
Philadelphia, Pennsylvania
While wrong site surgery is not an everyday occurrence, all
facilities and physicians who perform invasive procedures are
at some degree of risk. The magnitude of this risk is often
unknown or undened. Providers who ignore this fact, or rely
on the absence of such events in the past as a guarantee of
future safety, do so at their peril. Unless an organization has
taken a systematic approach to studying its own processes, it
is ying blind, says Mark R. Chassin, MD, FACP, M.PP, MPH.,
president, The Joint Commission. These eight organizations
are leading the way in nding specic solutions to the complex
problem of wrong site surgery.
Wrong site surgery includes invasive procedures on the wrong
patient as well as wrong procedure, wrong site, and wrong side
surgeries. The Joint Commission has been
at the forefront of the wrong site surgery
issue for many years, issuing Sentinel Event
Alert newsletters in 1998 and 2001 on
wrong site surgery. The Joint Commission
later convened a Wrong Site Surgery Sum-
mit that led to the development of the Uni-
versal Protocol, a standardized approach to eliminating wrong
site surgery. Use of the Universal Protocol, which includes a
pre-procedure verification, site marking and a Time Out, is
an accreditation requirement for Joint Commission-accredited
hospitals, ambulatory care and ofce-based surgery facilities.
Additional projects underway by the Center
for Transforming Healthcare
In addition to wrong site surgery, the Center is working to
reduce surgical site infections following colorectal surgery
through a project launched in August 2010 in collaboration with
the American College of Surgeons. The solutions for this proj-
ect are expected to be published in late 2011 or early 2012.
A new project, Preventing Avoidable Heart Failure Hospitaliza-
tions, launched in March 2011.
All Joint Commission-accredited health care organizations
have access to the solutions through the Targeted Solutions
Tool (TST), which provides a step-by-step process to meas-
ure performance, identify barriers to excellent performance,
and implement the Centers proven solutions that are cus-
tomized to address an organizations specic barriers. The rst
set of targeted solutions, created by eight of the countrys lead-
ing hospitals and health care systems working in collaboration
with the Center, focuses on improving hand hygiene. Accred-
ited organizations can access the TST and hand hygiene
solutions on their secure Joint Commission Connect extranet.
Targeted solutions for wrong site surgery are expected to be
added to the TST in the fall of 2011. Solutions for hand-off
communications, another Center project, are expected to be
added in late 2011. Future projects are expected to focus on
medication errors, and other aspects of infection control.
The Center is grateful for the generous leadership and support
of the American Hospital Association, Blue Cross and Blue
Shield Association, BD, Ecolab, Cardinal Health, GE Health-
care, GlaxoSmithKline (GSK), Johnson & Johnson and Med-
line Industries, Inc., as well as the support of GOJO Industries,
Inc. and Federation of American Hospitals.
For more information about the Joint Commission Center
for Transforming Healthcare, visit www.centerfortransform-
inghealthcare.org.
Root Cause Information for Wrong-patient,
Wrong-site, Wrong-procedure Events Reviewed
by The Joint Commission
(Regardless of the magnitude of the procedure)
Leadership 607
Communication 499
Human Factors 459
Information Management 262
Operative Care 249
Assessment 236
Physical Environment 74
Patient Rights 44
Anesthesia Care 40
Continuum of Care 28
2004 through Second Quarter 2011 (N=732). The majority of
events have multiple root causes
The reporting of most sentinel events by The Joint Commission is volun-
tary and represents only a small proportion of actual events. Therefore,
these root cause data are not epidemiologic data set and no conclusions
should be drawn about the actual relative frequency of root causes or
trends in root causes over time.
160
140
120
100
80
60
40
20
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
(Q2)
Wrong-patient, Wrong-site, Wrong-procedure Events
Reviewed by The Joint Commission
(Regardless of the magnitude of the procedure)
20 The ORConnection
The South Carolina Hospital Association is partnering with Atul Gawande,
MD, renowned surgeon and co-creator of the WHO Surgical Safety Check-
list, to implement the WHO Surgical Safety Checklist in every operating
room across the United States by 2015.
The initiative has begun in South Carolina, where all of the hospitals have
committed to routinely use the checklist in their operating rooms by the end
of 2013. The knowledge gained through the South Carolina hospitals
experiences will later serve as a model for implementing the WHO Surgical
Safety Checklist in hospitals and surgery centers nationwide and around
the world.
CDC Issues New Guidelines for Preventing
Norovirus in Healthcare Settings
4
The Centers for Disease Control and Prevention (CDC)
recently released guidelines for preventing and controlling
norovirus gastroenteritis outbreaks in healthcare settings. The
guidelines, titled Guideline for the Prevention and Control of
Norovirus Gastroenteritis Outbreaks in Healthcare Settings,
2011, include recommendations related to patient cohorting
and isolation precautions; hand hygiene; patient transfer and
ward closure; indirect patient care staff; diagnostics; personal
protective equipment; environmental cleaning; staff leave;
visitors; education; and communication. To access the guide-
lines, go to www.cdc.gov/hicpac/norovirus/002_norovirus-
toc.html.
Nevada Enacts Patient Safety
Checklist Law
2,3
A new law effective July 1, 2011 requires Nevada hospitals
to create and adopt patient safety checklists that must
include without exception:
1. A checklist for ensuring that the patient is being provided
the treatment ordered by a healthcare provider. The check-
list must also include a stipulation requiring providers to
positively identify the patient upon each interaction.
2. A checklist for ensuring that each healthcare provider
adheres to universal precautions including washing his
or her hands before and after every patient interaction
and after touching a surface or object that may
be contaminated.
PATIENT SAFETY NEWS PATIENT SAFETY NEWS
WHO Surgical Safety Checklist to
Be Implemented Nationwide by 2015
1
References
1. SC hospitals partner with Dr. Atul Gawande [news release]. Hilton Head, SC: South Carolina Hospital Association; October 4, 2010. http://www.scha.org/news/sc-hospitals-
partner-dr-atul-gawande. Accessed June 8, 2011.
2. Patient safety checklists become law in Nevada. This Week at the Institute for Healthcare Improvement newsletter. June 6, 2011.
3. Assembly Bill No. 280. State of Nevada. Available at: http://www.scribd.com/doc/50928544/AB-280-Bill-Text-Nevada-Legislature-via-MyGov365.com. Accessed June 8, 2011.
4. CDC Issues Guidelines for Preventing Norovirus in Health Care Settings. Health e-News+ . Ohio Hospital Association website. Available at: http://www.ohanet.org/-
Newsletter-Issue/newsletterissueHealthENews050911. Accessed June 20, 2011.

Retained Surgical Items
AORNs latest condence-based learning (CBL) module.
AORNs Condence Based Learning (CBL) is a
unique educational program that is designed to
help you achieve mastery in both knowledge and
condence of that knowledge when providing care
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learner in reducing time to master knowledge and
increasing retention of critical information.
I N T R O D U C I N G
2011 Medline Industries, Inc.
22 The ORConnection
The top priorities for organizations in 2011 are very simply
stated, but not easily executed. Here are the most important
areas of focus:
Staff engagement and loyalty (HCAHPS)
Nursing and physician engagement and collaboration
(HCAHPS)
Excellence with delivering the patient experience
(HCAHPS)
Reliable care that is founded on best practice quality
and safety practices (Pay for Performance -
Value Based Purchasing - Core Measures / SCIP /
Hospital-Acquired Conditions)
Nursing staff at the forefront of designing, developing
and implementing solid EMRs (Meaningful Use-
Patient Protection Accountability Care Act-PPACA)
Excellent, system-focused leaders who care and
engage all staff on their excellence journey
An environment that fosters and supports the
STEEEP aims of Lean/Six Sigma (Safe-Timely-
Effective-Equitable-Efcient-Patient-Centered Care)
Building strong partnerships internally and externally is a neces-
sity for a successful health system. Interdisciplinary teams that
include: nurses, materials managers, purchasing, CWOCNs,
infection control preventionists, physicians, chief medical ofcers
and chief nursing ofcers must come together to evaluate current
clinical and service excellence delivery. Innovation and change
management will be a necessary core competency of staff and
leaders in positions to inuence excellence.
The ideal state for CNOs and clinical leaders is to have collabo-
ration and standards in practice, processes, and leadership
across our nation. Remember, if excellence was that easy, we
would have nailed this years ago. Florence Nightingale instructed
us, First Do No Harm. Lets continue to learn from one
another and provide our staff, physicians and patients with
excellence, and of course, eliminate harm.
2011 Nursing Leadership Priorities:
The CNOs Perspective
by Candace S. Smith, MPA, RN, NEA-BC
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around the world, and the vast majority of these are catheter-associated urinary tract infections (CAUTIs).
As many as half of urinary catheters are placed inappropriately, and one third remain in place longer than
medically necessary.
Physicians often forget that their patients are catheterized or do not remember why they have urinary catheters.
The Centers for Medicare & Medicaid Services does not reimburse for CAUTIs that are not present on admission.
Urinary catheters are inserted for a variety of medically necessary reasons, but as these statements indicate, they can
also cause medical harm. Fortunately, the majority of CAUTIs can be prevented by strict adherence to evidence-based
guidelines. In Spring 2011, The Joint Commission introduced a new National Patient Safety Goal to prevent CAUTIs.
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is your authoritative guide to ensure the safety of patients who have urinary catheters. Features include:
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properly securing and positioning the collection system, maintaining a closed system,
and checking the collection system
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including equations for outcome and process measures
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26 The ORConnection
Unlikely Heroes
Tragedy inspired three women to
become infection prevention pioneers
When a family member goes into the hospital, your expectations are that your child, husband or parent will receive
excellent, safe care, recover and go home. Unfortunately, this isnt always the case. In fact, 4,600 patients become
infected each day from a healthcare complication. And 271 patients die each day as a result of a facility-
acquired infection.
1
Human lives are cut short because of a horric, widespread and
preventable problem. The hospitals where these tragedies
occur also suffer the consequences of their mistakes. Bad
press and lawsuits emerge from the anger and confusion of
frustrated families seeking answers. However, theres hope in
the form of three unlikely heroes: Sorrel King, Victoria Nahum
and Deborah Adler. Each woman, in her own way, is pioneer-
ing patient safety efforts inspired by extremely painful personal
experiences.
Sorrel King
A little more than 10 years ago, Sorrel Kings daughter, Josie,
was admitted to the hospital for second-degree burns she suf-
fered from hot bath water. Two days before her scheduled return
home, she died from severe dehydration and misused narcotics.
Josie King was just 18 months old, and her heart stopped from
an avoidable misunderstanding. Following their tragedy, Sorrel
King and her husband, Tony, founded the Josie King Foundation.
They began working with hospitals across the country with the
goal of promoting patient safety.
Sorrel King has traveled every corner of the country to create a
culture of patient safety, and her innovations have redened how
medical errors are prevented. Through the Josie King Founda-
tion, she has established safety programs in hospitals, care
journals for patients and families to record information, a
research project on therapeutic writing for nurses, book clubs
based on her book, Josies Story, and nursing awards to pro-
mote good practices.
Sorrel King
Sorrel King and
daughter, Josie
Patient Safety
Victoria Nahum Deborah Adler
Victoria Nahum
As if one tragedy is not enough for one person to bear, Victoria
Nahum saw the same misfortune play out three times. A close
relative, Victoria herself, and Victorias son were each infected in
just 10 months time, ending with the death of Claudias son,
Josh. He was 27. Angered and ultimately inspired by the loss of
their son, Nahum and her husband, Armando, founded the Safe
Care Campaign to focus on infection prevention and identify and
implement solutions to save lives. Safe Care works with hospitals
to change current practices for enhanced patient safety. The
initiative also works with patients to help them understand what
is safe and what kinds of practices to look for.
Deborah Adler
Deborah Adlers grandmother, Helen, accidentally swallowed her
husbands medication because she could not clearly identify her
own pill bottle among the many bottles in her medicine cabinet.
Fortunately, Helen was not severely harmed by the accident. At
the time, Adler was persuing her Master of Fine Arts (MFA) at
the School for Visual Arts in New York City. The incident inspired
her to create not only a more attractive pill bottle, but a safer
prescription packaging system that clearly communicates the
necessary information to patients so they know exactly what
they are taking. Adlers design included color-coded labels to
personalize prescriptions for each member of a household. She
took her design ideas to Target, and they quickly saw the enor-
mous benets. Her ClearRx
prescription-packaging system is
now standard in Target pharmacies across the country.
Victoria Nahums husband, Armando, and son, Josh
Deboarh Adler and
grandmother, Helen
28 The ORConnection
ClearRx is raising awareness in the medical community, the
design community, and in popular culture, Deborah said.
People are paying closer attention to what the patient gets at
the end of the day. Throughout this process, I have learned rst
hand that design has the power to make a difference.
Adler also works with Medline to design packaging for
its clinical products and programs to help clinicians use
products correctly and reduce variance in the procedure.
Specically, she has assisted in the development of clinical
programs to aid in reducing healthcare-acquired conditions,
including catheter-associated urinary tract infections and
ventilator-associated pneumonia.
Each of these women took her heartbreak and decided to help
x a broken system. Rather than passively grieving their losses,
King, Nahum and Adler are taking action. Rather than ignoring
or circumventing the healthcare hierarchy, they partner with it.
Rather than burying their feelings, they share their ideas in
efforts to make health care as transparent as it should be. They
each travel across the nation armed with their stories, their
insights and their passion to ght an uphill battle against
dangerous apathy.
These women have a message that goes beyond a lack of
precision due to human error. Their message is one of caring.
Their stories are exactly what anyone within the health care
needs to hear because simply, theyre stories anyone can
understand.
These women werent activists or philanthropists before their
tragedies. King and Nahum were mothers and Adler was a stu-
dent. King says in her book, Josies Story, I am not a doctor or
a nurse and I knew absolutely nothing about the health care
industry. All I knew was that Josie died from medical errors
a breakdown in the systempoor communication, and I was
determined one way or another to prevent that from happening
to anyone else.
These women are people who didnt think twice about trusting
their children to men and women in scrubs; they were people with
tragedies that didnt have to be. They preach the message of
prevention with an empirical appeal, but they also preach
(and practice) the message of getting people to care about this
pervasive problem. Reminding doctors and nurses of the essence
of their professionthat prevention is the best medicine, the best
step towards truly improving patient safety.
These women have a message that goes
beyond a lack of precision due to human
error. Their message is one of caring.
ClearRx
prescription drug packaging

Reference:
1. Infection facts you need to know. Safe Care Campaign website. Available at:
www.safecarecampaign.org/Welcome.html. Accessed August 12, 2011.
Clearrx
is a registered trademark used for Retail Pharmacy Services and owned

by Target Brands, Inc..
Read Josies Story
Medical errors are a leading cause of death in the United States, but the subject has
long been taboo. All that changed after Sorrel Kings 18-month-old daughter, Josie,
died in the hospital after a series of medical errors. Josies Story is an account of one
womans unlikely path from full-time mom to nationally renowned patient advocate and
an inspirational chronicle of how a motherand her unforgettable daughterare
transforming the face of American medicine.
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30 The ORConnection
ARROGANT,
ABUSIVE AND
DISRUPTIVE
AND A
by Laurie Tarkan, The New York Times
It was the middle of the night, and Laura Silverthorn, a nurse at a
hospital in Washington, knew her patient was in danger.
The boy had a shunt in his brain to drain uid, but he was vomiting and had an extreme headache,
two signs that the shunt was blocked and uid was building up. When she paged the on-call resident,
who was asleep in the hospital, he told her not to worry.
After a second page, Ms. Silverthorn said, he became arrogant and said, You dont know what to
look for youre not a doctor.
He ignored her third page, and after another harrowing hour she called the attending physician at
home. The child was rushed into surgery.
He could have died or had serious brain injury, Ms. Silverthorn said, but I was treated like a pest for
calling in the middle of the night.
Her experience is borne out by surveys of hospital staff members, who blame badly behaved doctors
for low morale, stress and high turnover. (Ms. Silverthorn said she had been brought to tears so many
times that she was trying to start her own business and leave nursing.)
Recent studies suggest that such behavior contributes to medical mistakes, preventable complica-
tions and even death.
It is the health care equivalent of road rage, said Dr. Peter B. Angood, chief patient safety ofcer at
the Joint Commission, the nations leading independent hospital accreditation agency.
DOCTOR!
OR Issues
Its the health care equivalent of

road rage.
He was afraid to contact the attending physician, who was
notorious for yelling and ridiculing the residents, Ms. Sweet
said. The baby died.
Of course, most doctors do not spew insults or intimidate
nurses. Most people are trying to do the best job they can
under a high-pressure situation, said Dr. Joseph M. Heyman,
chairman of the trustees of the American Medical Association.
Dr. William A. Norcross, director of a program at the University
of California, San Diego, that offers anger management for
physicians, agreed. But he added, About 3 to 4 percent of
doctors are disruptive, but thats a big number, and they really
gum up the works. Experts say the leading offenders are spe-
cialists in high-pressure elds like neurosurgery, orthopedics and
cardiology.
In one instance witnessed by Dr. Angood of the Joint Commis-
sion, a nurse called a surgeon to come and verify his next sur-
gical patient and to mark the spot where the operation would be
done. The harried surgeon yelled at the nurse to get the patient
ready herself. When he showed up late to the operating room,
he did not realize the surgery site was mismarked and operated
on the wrong part.
The surgeon then berated the entire team for their error and
continued to denigrate them to others, when the error was the
surgeons because he failed to cooperate in the process, Dr.
Angood said.
A hostile environment erodes cooperation and a sense of com-
mitment to high-quality care, Dr. Angood said, and that
increases the risk of medical errors.
When the wrong surgery is done on patients, he said, often
there is somebody in that operating room who knew the event
was going to occur who did not feel empowered enough to
speak up about it.
32 The ORConnection
A survey of health care workers at 102 nonprot hospitals from
2004 to 2007 found that 67 percent of respondents said they
thought there was a link between disruptive behavior and med-
ical mistakes, and 18 percent said they knew of a mistake that
occurred because of an obnoxious doctor. (The author was Dr.
Alan Rosenstein, medical director for the West Coast region of
VHA Inc., an alliance of nonprot hospitals.)
Another survey by the Institute for Safe Medication Practices, a
nonprot organization, found that 40 percent of hospital staff
members reported having been so intimidated by a doctor that
they did not share their concerns about orders for medication
that appeared to be incorrect. As a result, 7 percent said they
contributed to a medication error.
There are signs, however, that such abusive behavior is less
likely to be tolerated. Physicians and nurses say they have seen
less of it in the past 5 or 10 years, though it is still a major prob-
lem, and the Joint Commission is requiring hospitals to have a
written code of conduct and a process for enforcing it.
Still, every nurse has a story about obnoxious doctors. A few
say they have ducked scalpels thrown across the operating
room by angry surgeons. More frequently, though, they are
belittled, insulted or yelled at often in front of patients and
other staff members and made to feel like the bottom of the
food chain. A third of the nurses in Dr. Rosensteins study were
aware of a nurse who had left a hospital because of a disrup-
tive physician.
The job is tough enough without having to prepare yourself
psychologically for a call that you know could very well become
abusive, said Diana J. Mason, editor in chief of The American
Journal of Nursing.
Laura Sweet, deputy chief of enforcement at the Medical Board
of California, described the case of a resident at a University of
California hospital who noticed a problem with a fetal monitor-
ing strip on a woman in labor, but didnt call anyone.
The surgeon then berated the entire
team for their error and continued
to denigrate them to others.
Continued on page 34
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Dr. Norcross blamed the brutal training surgeons get, the long
hours, being belittled and pimped a term for being bom-
barded with questions to the point of looking stupid. That
whole structure teaches a disruptive behavior, he said.
Dr. Norcross and other experts said staff members under-
standable reluctance to challenge a physician, especially a pop-
ular surgeon who attracts patients to the hospital, created an
atmosphere of tolerance for the bad behavior and indifference.
So did a tendency among doctors to form old boy networks
and protect one another from criticism.
But things have begun to change. Today, good communication
and leadership are two of the six core skills taught in medical
schools and residency programs. More nurses are challenging
doctors on their inappropriate behavior, and fewer hospitals are
tolerating disruptive doctors. Today theyre getting rid of that
doctor or sending them to anger management, said Dr.
Thomas R. Russell, executive director of the American College
of Surgeons.
Hospitals have also developed more formal and consistent
ways of addressing disruptive behavior, Dr. Rosenstein said.
They are also trying to improve relations and mutual respect
between doctors and nurses.
At John Muir Health, a nonprot group of two hospitals in Wal-
nut Creek and Concord, Calif., a committee of physicians,
nurses and other staff members was formed to focus on col-
laboration and communication between disciplines.
When complaints are submitted, we try to be proactive early to
let them know there is not going to be any tolerance for that,
said Dr. Roy Kaplan, John Muirs medical director for quality.
Tips for stopping physicians
from behaving badly
1,2
Establish a written code of conduct that clearly outlines
acceptable standards of behavior.
Develop a system for monitoring compliance with the code
of conduct that includes regular staff surveys, focus groups,
peer and team member evaluations and rounding to directly
observe disruptive behavior.
Enforce all code violations promptly and thoroughly.
Establish a physician peer review system to review
complaints about physicians. The panel must be viewed
as advocating for physicians, not as their adversary.
Develop a clear policy of non-retaliation for team members
who submit complaints. The policy must clearly state that
all staff members and physicians will be protected against
retaliation for reporting code violations or for assisting with
related investigations.
The earlier a peer intervention can occur, the better. When
intervention occurs, describe the behavior objectively to
the physician in question. Its not uncommon for disruptive
physicians to deny that their behavior is unacceptable
or abusive. Be prepared for this type of reaction.
If the doctor refuses to deal with the problem, appropriate
consequences must be in place. A loss of privileges might
represent the most severe consequence.
Try to prevent disruptive behavior by implementing best
practices designed to improve relationships among
members of the healthcare team.
References
1 Pilla L. Dealing with difcult surgeons. Outpatient Surgery Magazine.
2002; 3(12). Available at: http://www.outpatientsurgery.net/issues/-
2002/12/dealing-with-difcult-surgeons. Accessed June 16, 2011.
2 Porto G and Lauve R. Disruptive clinician behavior: a persistent threat
to patient safety. Patient Safety & Healthcare Quality website. July/-
August 2006. Available at: http://www.psqh.com/julaug06/disruptive-
.html. Accessed June 16, 2011.

S
D
A
34 The ORConnection
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References:
1. Occupational Safety and Health Standards, Toxic and Hazardous Substances,
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Some physicians worry that hospital administrators will abuse
the stricter codes of conduct by using them to get rid of doc-
tors who speak out against hospital policies. And the Joint
Commission rulings have spawned a cottage industry of anger
management centers and law rms defending hospitals or
physicians.
Professionals like Ms. Silverthorn, the nurse in Washington, said
the change was overdue.
We go to school, we have a very important job, but theres no
respect, she said.
She recalled a particularly humiliating moment on Dec. 25,
2006. Working in the pediatric emergency room, she called a
drug by its generic name rather than its brand name.
I was quickly shouted out of the trauma room and humiliated
in front of everyone, she said. But while everyone knew the
doctor was actually the one who didnt know what he was
doing, she continued, no one said a word.
From The New York Times, December 2, 2008 2008 The New York Times.
All rights reserved. Used by permission and protected by the Copyright
Laws of the United States. The printing, copying, redistribution, or
r etransmi ssi on of thi s Content wi thout express wri tten permi ssi on
i s prohibited.
Additional reading
On Target: Managing Disruptive Physician Behavior. American
College of Physician Executives. Available at:
http://net.acpe.org/resources/publications/OnTargetDisruptive-
Physician.pdf.
Rosenstein AH. Measuring and managing the economic impact
of disruptive behaviors in the hospital. Journal of Healthcare Risk
Management. 2009; 30(2):20-26.
Disruptive and Unprofessional Behavior. Agency for Healthcare
Research and Quality website. Available at:
http://psnet.ahrq.gov/primer.aspx?primerID=15.
Knox R. Doctors behaving badly? They say it happens all the
time. National Public Radio (NPR) website. Posted May 25, 2011.
Available at: http://www.npr.org/blogs/health/2011/05/28/13664
8516/doctors-behaving-badly-they-say-it-happens-all-the-time
I was quickly shouted out of the

trauma room and humiliated in
front of everyone.
36 The ORConnection
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38 The ORConnection
Cleared
for takeoff?
The deadly airplane crash that
inspired the development of
crew resource management
It wa
173
wer
sma
Isla
Can
It w
two
to m
so m
Afte
Gra
land
Pre
Air t
480
way
the
the
of th
a 18
way
turn
Misc
see
The
high
KLM
adv
hou
forc
tions
a sp
time
and
Hav
to p
the
nee
was
rass
But
it. A
cras
Airp
It was March 27, 1977, and KLM Flight 4805 and Pan Am Flight
1736, along with at least 10 additional commercial airplanes,
were temporarily grounded, crowded onto the tarmac at the
small Los Rodeos Airport on the island of Tenerife in the Canary
Islands. Flights had been diverted there from nearby Gran
Canaria Airport, where a terrorist bomb had just exploded.
It was a Sunday, so the control tower at Los Rodeos had only
two air trafc controllers on duty. In addition, a dense fog began
to move in altogether less than ideal conditions, especially with
so many planes grounded at the small airport.
After several hours, the Los Rodeos tower received word that
Gran Canaria Airport had reopened and planes could begin
landing there again.
Preparing planes for takeoff
1
Air trafc controllers at Los Rodeos decided to have KLM Flight
4805 and Pan Am Flight 1736 which were closest to the run-
way, prepare for takeoff rst. The air trafc controllers radioed
the planes to begin slowly taxiing down the runway, one behind
the other. The plan was that the KLM plane, which was ahead
of the Pan Am plane, would taxi to the end of the runway, make
a 180-degree turn, and then begin takeoff facing the opposite
way down the runway. In the meantime, the Pan Am plane would
turn left off the runway, allowing full clearance for the KLM plane.
Miscommunication and thickening fog, however, made this
seemingly simple plan very difcult to carry out.
The KLM ight captain, Jacob Van Zanten, a highly respected,
highly experienced pilot, who was in charge of training all of
KLMs 747 pilots and who also served as the face of KLM in
advertisements, was anxious to get on his way. With several
hours of ying already logged for this trip, further delays would
force him to ground the airplane in order to meet ight regula-
tions that require pilots to limit the number of hours they y during
a specied time period. Van Zanten wanted to make sure he had
time to get to Gran Canaria Airport, drop off passengers there,
and then immediately take off for the Netherlands, as planned.
Having to ground the plane would mean huge expenses for KLM
to provide overnight accommodations for all passengers plus
the crew. It would also leave the airline one plane short for ights
needing to go out of the Netherlands. High-ranking Van Zanten
was motivated to do everything he could to avoid the embar-
rassment of not being able to carry out his original ight plan.
But as it turned out, Van Zanten did not meet his goal. Far from
it. A total of 583 passengers and crew perished in a ery runway
crash with the Pan Am plane that fated Sunday at Los Rodeos
Airport.
How did it happen?
1
As the fog thickened, visibility was only 15 to 21 feet. This meant
the air trafc controllers could not see the planes and the planes
could not see each other. In addition, the Pan Am plane ran into
problems when it was time to turn off the runway. The tower told
them to turn at turnoff number 3, however, that turnoff didnt
make sense to the cockpit crew because it would mean taking
a sharp 45-degree turn, leaving the plane facing in the wrong
direction for takeoff later. It was also unclear how the turnoffs
were to be counted. Were they supposed to count the rst turn
they made onto the runway as turnoff 1, or would turnoff 1 be
the rst turnoff they saw once they got onto the runway?
The confusion between the tower and the Pan Am plane was
costing more time, and Van Zanten became more impatient.
Once he turned around at the end of the runway, he wanted to
immediately prepare for takeoff. His co-pilot chided him for
beginning to do so without clearance from the tower, so Van
Zanten angrily ordered the co-pilot to get clearance to prepare
for takeoff. The next communication they would need from the
tower would be clearance to actually take off. The co-pilot
apparently became intimidated by Van Zantens attitude and
stayed quiet thereafter, no longer questioning Van Zantens
decisions. Sure enough, without any communication with the
tower, Van Zanten began taking off, saying he knew he could
gain enough altitude to y over the Pan Am plane.
A fatal decision
With visibility so poor, Van Zanten couldnt see how close the
Pan Am plane was, and as the KLM plane began to lift off the tar-
mac, the lower part of its fuselage struck the upper fuselage of
the Pan Am plane, which was in the process of turning off the
runway.
2
The planes collided, creating an immense reball with
no survivors from the KLM ight and few survivors from the Pan
Am ight. It is still the deadliest air crash on record; one of the
reasons being tension in the cockpit when the KLM pilot refused
to check his ego at the door and respectfully listen to sound advice from
his co-pilot.
After the crash at Tenerife, the airline industry modied cockpit
procedures to deemphasize the hierarchy among crew mem-
bers. Known in the industry as crew resource management,
this way of operating is now standard among the airline indus-
try worldwide.
Sources
1. The Deadliest Plane Crash. NOVA website lm. Available at:
http://www.pbs.org/wgbh/nova/space/making-air-travel-safer.html.
Accessed June 29, 2011.
2. Krock L. Making Air Travel Safer. NOVA website. Posted, February 17,
2004. Available at: http://www.pbs.org/wgbh/nova/space/making-
air-travel-safer.html. Accessed June 29, 2011.
Special Features
Sharon Bidwell, RN, BSHCA, CNOR, RNFA, Director of Surgical
Services for Unity Hospital in Rochester, NY, began implement-
ing crew resource management principles in her operating
rooms in 2007 with the introduction of a ight board.
She was familiar with the plane crash at Tenerife and the con-
cepts of crew resource management that were developed af-
terward. Another hospital in her area was conducting teamwork
training led by pilots, which inspired Sharon to incorporate the
principles at Unity.
The overall message, Sharon said, is that everyone is equally
responsible for safety.
The ight board is a poster that hangs in each operating room.
It lists items often found on a surgical safety checklist:
Date
Patients name
DOB
Name of procedure
UOP preop
EBL
Two patient identiers
Allergies
H & P/consent signed
Site verication
Fire triad
Name of antibiotics given
Time antibiotics were given
Redosing of antibiotics after 4 hours
DVT prophylaxis
Administration of preop beta blockers (if applicable)
Surgical time out to check patient, procedure and position
Verication of any implants or special equipment (if applicable)
Post op debrief: surgical procedure verication
Before surgery begins, all items on the list are agged red to
show that nothing has been veried yet. A designated team
member then begins reading each item on the checklist aloud.
Team members provide the answers aloud, and the leader slides
the indicator bar from red to green as the team members an-
swer. Each item must be conrmed by all team members before
it is changed to green.
The ight board really engages the entire team, Sharon said.
Plus, X-ray techs or relief staff who come in mid-surgery know
exactly whats going with a quick glance at the ight board.
Crew Resource Management
in Action at Unity Hospital
40 The ORConnection
Its such a wonderful check. It allows for active listening and the
ability to speak up. We dont care your position, speak up. We
all have a piece in this, Sharon added.
Sharon said surgeons balked a bit at the idea of the ight board
at rst, but now that it has been in use almost four years, every
surgeon has realized its value. One example of a save was a
patient allergy to metal that did not come up until the ight board
was completed. With metal instruments and retractors routinely
used in surgery, the case had to be postponed.
Unity Hospital has not experienced any sentinel events since
implementing ight boards; and to Sharons knowledge, no sen-
tinel events have occurred going back to at least 1998.
When the Joint Commission and OSHA observed surgery at
Unity, Sharon said they were very impressed with the ight
boards. They had not seen anything like it at other hospitals.
Sharons next goal is to go electronic with the flight boards,
integrating them into the patient electronic medical record.
To contact Sharon Bidwell,
email sbidwell@unityhealth.org.
Flight board before surgery begins. All items are agged red. Flight board after team review. Items are agged green.
OR Issues
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HIGH VISCOSITY TISSUE ADHESIVE
by Rebecca McPherson, MSN, RN
Preventing surgical site infections is a multidisciplinary effort.
Educating nurses, surgical technologists, patient care techni-
cians, and our physicians is critical. Suggest that nursing leaders
provide competencies that support best practices in the pre-
vention of surgical site infections. Also, it is important to
observe best clinical practice in the surgical areas. It is necessary
to implement a monitoring and or surveillance process to help
support staff in the accountability of preventing surgical site
infections.
Facts and interventions to share
with your nursing education teams
According to the Centers for Disease Control and Prevention,
(CDC), patients who have health problems such as diabetes, obe-
sity, or allergies are at higher risk for developing complications.
Individuals who suffer from cancer, liver, or kidney conditions or
who smoke may experience slower healing.
Other risk factors for developing an infection after surgery include
operating on an infected wound or traumatic injuries that involve
removal of foreign objects, such as metal and glass, from bodily
tissue. Patients with weakened immune systems who may be tak-
ing anti-cancer or steroid medications are also at risk.
Signs and symptoms of surgical site infections include:
Drainage of cloudy uid from the surgical site
Fever
Swelling that extends beyond the surgical site
Surgical site not healing as expected
The CDC recommends that patients shower or bathe with an
antiseptic on at least the night before the operative day.
1
In 2008,
the Association of Perioperative Registered Nurses revised its
recommendation concerning preoperative skin preparation for
patients who are scheduled for open, class I surgical procedures
that take place below the chin to bath or shower with chlorhex-
idine gluconate (CHG) unless contraindicated, which will reduce
the skins natural ora
6
.
According to the CDC, in order to prevent SSIs,
doctors, nurses and other healthcare providers
should do the following:
Clean their hands and arms up to their elbows with an
antiseptic agent just before the surgery.
Clean their hands with soap and water or an alcohol-based
rub before and after caring for each patient.
Remove some of the patients hair immediately before your
surgery using electric clippers if the hair is in the same area
where the procedure will occur. The patient should not be
shaved with a razor.
Wear hair covers, masks, gowns, and gloves during surgery
to keep the surgery area clean.
Give your patient antibiotics before the surgery starts. In most
cases, the patient should have antibiotics within 60 minutes
before the surgery starts and the antibiotics should be
stopped within 24 hours after surgery.
Educate patients regarding signs and symptoms of surgical
site infections before they go home to avoid complications
and readmissions.
Infections
Facts, gures and interventions
to help you improve your outcomes
Surgical-Site
Patient Safety
44 The ORConnection
Finally, staff engagement through the creation of a culture of
excellence is what will support the reduction in patient harm
due to surgical site infections and overall. Remember to share
data, frequently, so staff can make changes in their behaviors
and practice, accordingly.
References
1 Mangram AJ, Horan, TC, Pearson, ML, Silver, LC, Jarvis, WR. The Hospital
Infection Control Practices Advisory Committee. Guideline for the prevention of
surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:247-280.
2 Cheadle WG. Risk Factors for surgical site infection. Surg Infect. 2006:7 Supp
1:S7-11.
3 Perencevich EN, Sands KE, Cosgrove SE, et al. Health and economic impact of
surgical site infections diagnosed after hospital discharge. Emerg infect Dis.
2003; 9(2):196-203.
4 Edmiston CE, Seabrook GR, Johnson CP, Paulson DS, Beausoleil CM.
Comparative of a new and innovative 2 percent chlorhexidine gluconate-
impregnated cloth with 4 percent chlorhexidine gluconate as topical antiseptic
for preparation of the skin prior to surgery. Am J Infect Control. 2006; 35(2):89-96.
5 Kirkland KB, Briggs JP, Trivette SL, et al. The impact of surgical site infections in
the 1990s: attributable mortality, excess length of hospitalization, and extra costs.
Infect Control Hosp Epidemiol. 1999;20:725-730.
6 Whitehouse JD, Friedman D, Kirkland KB, Richardson WJ, Sexton D. The impact
of surgical site infections following orthopedic surgery at a community hospital
and a university hospital: adverse quality of life, excess length of stay, and extra
cost. Infect Control Hosp Epidemiol. 2002; 23(4):183-189.
7 Association of periOperative Registered Nurses. Recommended practices for
perioperative patient skin antisepsis. In: Conner R, ed. 2009 AORN Perioperative
Standards and Recommendation Practices. Denver: AORN, Inc; 2009;549-567.
8 Preventing Surgical Site Infections. Institute for Healthcare Improvement (IHI)
website. Available at: www.ihi.org/IHI/Programs/AudioAndWebPrograms/Web-
Action_SSI.htm. Accessed June 28, 2011.
9 Surgical Site Infections. What is a surgical site infection? Available at:
http://www.drugs.com/ct/surgical-site-infections.html. Accessed June 27, 2011.
10 FAQs about Surgical Site Infections. Available at:
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/SSI_tagged.pdf.
Accessed July 6, 2011.
Rebecca McPherson, MSN, RN, is vice presi-
dent of clinical services for Medline Industries,
Inc. Prior to joining Medline, Rebecca worked
for Sherman Health Systems in Elgin, IL, as
director of operations for the immediate care
centers. Her background also includes emer-
gency room nursing.
SSIs by the numbers
Post-operative surgical site infections (SSIs) are the most
common healthcare-associated infection in surgical
patients,
1
occurring in up to ve percent of surgical
patients.
2
Between 500,000 and 750,000 SSIs occur annually in
the United States.
3,4
If an SSI occurs, a patient is 60 percent more likely to spend
time in the ICU after surgery than an uninfected surgical
patient.
4
The development of an SSI increases the hospital length
of stay by a median of two weeks.
5
SSIs develop in almost two percent of patients after
discharge,
2
and these patients are two to ve times as
likely to be readmitted to the hospital.
6,7
According to the Institute for Healthcare Improvement (IHI),
the development of an SSI can increase the cost
per episode from an estimated $2,734 to $26,019.
8
Surgical site infections most often develop within 5-10
days post surgery.
Infections develop in about one to three out of every
100 patients who have surgery.
9
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46 The OR Connection
Building a Culture
of Operating Room Safety
Using Crew Resource
Management
Stephanie McKoin, RN, BSN, MPAHSA, NEA-BC, Clinical Director of Surgical Services, York Hospital
Douglas Arbittier, MD, Chair, Department of Anesthesiology, and Medical Director, Perioperative Services, York Hospital
Virginia S. Wesner, MPA, Research Manager, Surgical Services, WellSpan Health
Donald W. Moorman, MD, FACS, Vice-Chair of Clinical Affairs and Associate Surgeon-in-Chief, Beth Israel Deaconess Medical Center,
and Associate Professor of Surgery, Harvard Medical School
John J. Castronuovo, Jr., MD, FACS, Director, Surgical Service Line, WellSpan Health, and Chair, Department of Surgery, York Hospital
Building a Culture
of Operating Room Safety
Using Crew Resource
Management
OR Issues
Arglaes provides:
Antimicrobial protection for up to 7 days
Moist wound healing
Fewer dressing changes
Non-staining
Transparency for wound monitoring
The Arglaes family of products has something
for every incision:
Arglaes Film is ideal for managing bacterial penetration
on post-op incision and line sites.
Arglaes Island features a calcium alginate pad for uid
management.
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Introduction
Crew resource management (CRM) can be defined as a group of techniques that can be
used by a crew or team to reduce human performance errors. Those techniques form
the basis of a training program that we used in the York Hospital operating room (OR)
to create a culture of safety.
CRM originated from a National Aeronautics and Space Admin-
istration workshop in 1979. In the 1960s and 70s, the aviation
industry began to realize that the primary cause of commercial
aviation accidents had shifted from equipment failure to human
error. The concepts and techniques encompassed in CRM help
teams perform at optimum levels, recognize and correct errors
and other threats, and reduce incidents and accidents. For sev-
eral years, commercial air carriers have utilized CRM techniques
to reduce human performance errors on the ight deck, thereby
reducing airline accidents. These techniques have proven so
successful that CRM training is mandated by the Federal Avia-
tion Administration, and CRM has been adapted in such diverse
activities as nuclear power station control rooms and medical
operating theaters.
1
York Hospital is a 572-bed, Magnet designated, nonprot com-
munity hospital located in York, Pennsylvania. In 2006, the hos-
pital began discussions to enhance the culture of safety in the
OR. In the ORs, despite implementing numerous nationally rec-
ognized safety initiatives, there continued to be a signicant
number of adverse outcomes, including retained foreign objects
and wrong-site surgeries. An internal analysis revealed that
some errors were related to issues of communication and coor-
dination of care. The surgical service line (SSL) leadership felt
that implementing a CRM training program for all members of
the OR team might lead to a decrease in these events. CRM
was chosen because it emphasizes techniques that improve
communication and interdependence among the team mem-
bers. These include briengs, a shared mental model, situational
awareness, debriengs, and communication techniques that
permit each team member to voice concerns in a timely way.
The SSL and patient safety ofcer evaluated several companies
and individuals prior to development of the CRM program. Crew
resource management has been adapted to healthcare in mul-
tiple formats. One of the earlier programs (introduced in 2000),
which has now been recognized with the prestigious Eisenberg
Award, was implemented by Benjamin Sachs and colleagues in
the Beth Israel Deaconess Medical Center (BIDMC) labor and
delivery unit in Boston, Massachusetts.
2-3
The SSL leadership had discussions with Donald Moorman, MD,
then at BIMDC, and developed a curriculum for the OR team
members. Moorman facilitated development of the delivery of
this curriculum by creating a model whereby successive teams
of learners drawn from the OR staff become team trainers. The
educational approach espoused by Moorman embraces a train
the trainers philosophy because it is more effective than
straightforward didactic instruction about the goals of highly
effective teams in creating cultural change. The SSL elected to
work with Dr. Moorman to adapt his program to our local needs.
The hospital CRM steering committee was created with leader-
ship representation from all stakeholder disciplines in our ORs.
The steering committee set its project goals and dened the
behaviors it wished to inculcate; developed its own curriculum;
enlisted surgeons, anesthesia providers, nurses, and surgical
technologists as the trainers; and developed its own training
videos and observational measurement tools to measure the
impact of the program on daily work performance. (See Table.)
Methods
Developing the York Hospital OR CRM training program was a
two-year project that required the commitment and attention of
the 17-member CRM steering committee. The steering com-
mittees primary focus was developing the CRM presentation
and acting as CRM trainers and champions by coaching surgi-
cal teams in the OR on conducting briefs and debriefs. In order
to facilitate day-to-day operations of the project, the CRM ex-
ecutive committee, consisting of the SSL medical director/chair
of the surgery department, clinical director of surgical services,
perioperative medical director/anesthesia department chair,
patient safety ofcer, and CRM project manager, was formed.
The CRM project manager was a designated assignment that
allotted 25% of the managers time to the project. The project
manager was responsible for logistically implementing the pro-
gram and developing program outcome measurement tools.
The total time commitment to complete the development and
implementation of this program was approximately 2,200 hours.
The members of the OR and the steering committee committed
to designing scenarios and presentations and producing videos,
with an emphasis on creating a hospital-centric program. This
commitment has been a primary factor in the positive reception
of the use of CRM techniques to foster better communication,
enhance teamwork, and improve patient safety.
The goal of York Hospitals CRM training program was to
encourage each OR team, as it gathers to perform a procedure,
to participate in a brief, creating the same mental model of the
goals to be accomplished at surgery. The brief included intro-
ductions of all team members; identication of the patient; con-
rmation of the procedure to be performed, as well as site, side,
or level; summation of the patients medical history; and antici-
pation of potential problems and key portions of the procedure.
Another goal of the CRM training was to encourage each OR
team to participate in a debrief to determine what went well and
Table. Curricular Goals of Crew Resource Management Team Training
Module/Length (MIN) Title Topics presented
Module 1/60 History of Crew Resource Management Analogy of aviation disasters to operating
and its Potential to Improve Patient Safety room misadventure,
Institute of medicine recommendations,
denition of a team
Module 2/30 How Team Leader Constitutes a Team Introductions, shared mental model, briengs,
team leaders role, situational awareness
Module 3/30 Effective Team Communication Differences in communication style between
disciplines, standards of effective
communication, information transfer
techniques, appropriately assertive
communication, conict management
Module 4/30 Postoperative Debrief Checklist, what went well, what could have
been done better, what were additional
resources needed that were not anticipated,
as well as follow-up on signicant events
what could have been done better, thus creating an environment
that encourages everyone, from surgeons to housekeeping staff,
to speak up i f they feel that pati ent safety needs to be
addressed.
The SSL charged the CRM steering committee to develop an
overall CRM delivery strategy. CRM team training consisted of
four modules: (1) the history of CRM and its potential to improve
patient safety, (2) how a team leader constitutes a team in the
OR, (3) effective team communication, and (4) postoperative
debrief. The modules were delivered to groups of 30 to 40 members
of the OR staff by various combinations of OR team members
who represented surgeons, anesthesia providers, and nursing
and OR staff.
To illustrate the modules, CRM steering committee members
acted in a series of videos, which were filmed in the OR. An
internal marketing campaign, including Wheres the Brief?
posters, was implemented along with monthly three-hour train-
ing sessions. To encourage attendance at educational sessions,
classes were approved for physician and nurse continuing edu-
cation credits and patient safety credits. Hospital staff members
were also compensated for their training time. To avoid closing
the OR, presentations were scheduled during the evening and
weekend hours. SSL leaders were present at every training ses-
sion given by steering committee members. Usually, a physician
member of the SSL acted as the program facilitator. The train-
ers for each session consisted of a surgeon or anesthesia
provider and a registered nurse or surgical technologist. The
educational sessions were attended by interdisciplinary teams
of surgeons, anesthesia providers, registered nurses, surgical
technologists, anesthesia and instrument technicians, secre-
taries, nursing assistants, and housekeeping staff. In addition to
the hospital-developed videos, two videos from the BIDMC pro-
gram were used to further emphasize the importance of using
CRM tools in the OR.
Results
In April 2008, the rst CRM training classes were given; by May
2009, more than 530 (98%) surgical services staff members
were trained. Anecdotal reports of staff practicing the CRM tech-
niques were noted in June 2008.
In evaluating the results of the implementation of CRM in the OR,
there has been a slight decrease in the percentage of problem-
atic responses in the Stanford Patient Safety Consortium:
Patient Safety Culture Survey from 15.9% in 2006 to 15.2% in
2008, scoring a lower percent problematic response than the
mean (17.2%) for all ORs in the consortium, as well as lower
than the overall hospital mean (16.1%) score. While some stud-
ies demonstrate a positive correlation between safety culture
and clinical outcomes, in our case, the Stanford survey was
coincidentally carried out before and after our CRM team train-
ing program and was not part of a study design. No p-value cal-
culations or formal statistical analysis has been done nor would
such analysis be appropriate. There also has been a slight
improvement in National Database of Nursing Quality Indicators
RN satisfaction scores in the RN:RN and RN:MD dimensions,
but this again is a coincidental observation and was not part of
a study design.
At the completion of team training, the brief/debrief utilization
rate was estimated in an observational study to be 67% and
42%, respectively. A year after the CRM training program was
initiated, a second observational study was implemented to
monitor progress and found that the brief/debrief utilization rate
had increased to 100% and 87%, respectively. We believe the
best evidence of success of our CRM program can be meas-
ured by the use of the brief and debrief because these moments
52 The ORConnection
of leadership and team cohesion have not been mandated but
rather are voluntarily adopted and observed. The effect of
observer presence in the OR may have been a factor in the
utilization rates, but the observers were medical students pres-
ent each summer for educational purposes and not identified
as observers collecting data.
Conclusion
We have demonstrated that a community teaching hospital can
develop and implement a CRM program tailored to local needs.
The response to our CRM program was the gradual adoption of
communication techniques and was best measured by assessing
the voluntary implementation of the brief and debrief. We have
utilized quarterly, joint grand rounds on patient safety topics to
re-emphasize the value of CRM. To measure progress, we have
developed several observational strategies that will help us monitor
CRM activity, including using a tracking system that indicates
when a brief/debrief activity is done during a surgical procedure
and, over time, looking at our data to see if there has been a
decrease in incidence of retained foreign objects and wrong-site
surgeries. Steady increases in the utilization of these CRM tech-
niques conrm that there has been widespread adoption of
CRM in the York Hospital OR. The SSL will continue to assess
the impact of the CRM program on changing the culture of
safety in the OR. We will continue to closely follow these trends
and others, including Agency for Healthcare Research and
Quality safety indicators, nurse satisfaction scores, and patient
outcomes (e.g., postoperative complication rates).
Notes
1. Fuller D. Crew resource management: reducing human performance
errors in space operations. Presented at: 20th AIAA International
Communication Satellite Systems Conference and Exhibit; 2002
May 12-15; Montreal, Quebec, Canada.
2. Sachs BP. A 38-year-old woman with fetal loss and hysterectomy.
JAMA 2005 Aug 17:294(7);833-40.
3. Pratt SD, Mann S, Salisbury M, et al. John M. Eisenberg Patient Safety
and Quality Awards. Impact of CRM-based team training on obstetric
outcomes and clinicians patient safety attitudes. Jt Comm J Qual
Patient Saf 2007 Dec;33(12):720-5.
This article is reprinted from the Pennsylvania Safety Advisory, Vol. 7, Suppl.
2-June 16, 2010. Available at: http://www.patientsafetyauthority.org/ADVI-
SORIES/AdvisoryLibrary/2010/jun16_7(suppl2)/Pages/01.aspx. The Advi-
sory is a publication of the Pennsylvania Patient Safety Authority, produced
by ECRI Institute and ISMP under contract to the Authority. Copyright 2010
by the Pennsylvania Patient Safety Authority.
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the ring stands and handed Angel the bag of
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SURGICAL PACKS
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sponge count. The SmartSponge System counts, locates
and recounts each sponge up to 80,000 times during a
single surgery. And because it is the only FDA-approved
system that uses radio-frequency identication, it uniquely
identies each sponge, so you can use the SmartWand-DTX
to nd missing sponges below, beside or inside a patient
Launch the QR app
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Medline Surgical Packs The Highest Quality Standards
Ovor 350 quality assuranoo spooialists
Our oustomor oomplaints navo droppod to tnoir lowost lovol
sinoo 2001, wnilo our produot output nas inoroasod oigntold
Produotion-lino inspootions witn pioturo-drivon
build instructions
Spooializod soalos along tno produotion lino woign
oaon paok to dotoot missing oompononts
Assombly in dodioatod oloan rooms
Our Kaizon program implomonts omployoo suggostions
or proooss improvomont and standardization
validatod EO storilization proooss
If there is a problem, our formal procedure includes:
nvostigation dotormining wny it napponod
Corrootion onsuring it doosn't nappon again
Communioation inorming all aootod oustomors
Satisaotion providing oustomors witn an appropriato
and timoly rosolution
MEDLNE
SUPGCAL PACKS
THE HIGHEST QUALITY STANDARDS
Over the 15 years that Ive been using Medline as
the manufacturer of my surgical procedure trays,
quality complaints have effectively gone down to zero.
Larry Creech, Senior Vice President, Carilion Clinic, Roanoke, VA
Our customer satisfaction has never been higher.*

*Internal trending data on le.
99.97

99.99
2
0
0
4

2
0
0
5

2
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6

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7

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9

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1
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A
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%
YEAR
SUSTAINED CUSTOMER ACCEPTANCE
CUSTOMER ACCEPTANCE RATE
The Basics of Todays
Surgical Mesh
And What The Future Holds
The surgical mesh market looks more like the cereal market
every day. There are hundreds of types, shapes and sizes, and
everyone has their favorite. When you look more closely, how-
ever; there are only a handful of true players in the market.
Each player is battling to deter new entrants from coming into
the market, spawning many useful and some not-so-useful
new products. This article will serve as a brief introduction to
the surgical mesh market and provide some additional insight
to help you digest all these new options.
Location, location, location
Surgical mesh is broken into two very broad categories based
on the location of use: inside or outside of the peritoneum. If a
surgical mesh is implanted inside the peritoneum it will require
a non-stick surface. Inside the peritoneum, the mesh will be in
direct contact with the small intestine. The purpose of the non-
stick surface is to allow the small intestine to continue moving
freely. Without this, the small intestine could create adhesions
or brous attachments to the implant. These adhesions could
then lead to a host of other issues, including bowel obstruction.
If the mesh is being implanted outside the peritoneum (pre-
peritoneal), the non-stick surface is unnecessary. Mesh with-
out this attribute is typically less expensive.
Inside the peritoneum
While the products used inside the peritoneum are more
expensive, they are also used in procedures that occur less
frequently. Flat sheets are most commonly used when inside
the peritoneum.
Flat sheets. Adhesions from the small intestine to the implant
are the largest concern for these implants. Any brous attach-
ments to the small bowel will cause pain, restriction on move-
ment and potential bowel obstruction. The most common
technologies to avoid adhesion incorporate either a temporary
or permanent barrier with a low coefcient of friction. In either
scenario, the coating facing the small intestine will engender
less irritation, heat and friction. These are believed to be the
root causes of tissue adhesions.
The permanent barrier used is called polytetrauoroethylene
or PTFE. Branded terms for PTFE include Teon and Goretex.
The common temporary barriers include caprolactone copoly-
mer, ORC, and Omega-3 fatty acid. There are many lms used
in this application. While each lm has slightly different bene-
ts, the end goal is the same; reduce chance for adhesion
while the body creates a new layer of peritoneum over the
mesh. Once this neoperitoneum has formed, the lm can then
be absorbed into the surrounding tissues.
Patches. The ventral patch is similar to the flat sheets in
design and technical requirements. The only difference is that
these patches are specically for open umbilical or incisional
hernia repair. Patches incorporate technology that allows them
to easily deploy around the defective site after insertion. Most
patches include a rigid ring in the circumference of the mate-
rial and straps. This rigid-elastic ring causes the implant to fold
open once inserted into the abdominal cavity, and the straps
allow it to be pulled taut to the abdominal wall.
One of the newer technologies to ensure the implant is in place
is the use of an inatable bladder. Using a bladder allows the
Special Feature
implant to deploy into the appropriate position. In addition to
placement, the balloon gives consistent radial pressure while the
implant is then sutured into place. This style of implant also
avoids the use of a rigid circumference of material. Many sur-
geons consider this an additional benefit of this emerging
design type.
Outside the peritoneum
As mentioned earlier, meshes used outside the peritoneum are
less expensive, and do not incorporate the anti-stick technol-
ogy. The most common operation using surgical mesh outside
the peritoneum is an inguinal hernia repair.
Flat sheets. The two most common materials for at sheets
outside the peritoneum are polypropylene and polyester. These
at sheets of mesh are used to spread out the tension of the
soft tissue repair over a greater surface area.
There has been a movement toward a few characteristics for
at sheet mesh; mono-lament, macro-porous and low weight.
Mono-lament and low-weight are seen as desirable features
because with implants, less is often more. Less material
implanted into the body results in less foreign body response to
the implant. Macro-pores serve to create space for tissue
in-growth in addition to reducing the surface area of the implant.
A few of the newer technologies that are emerging in at sheet
mesh are self-xation and resorbable components. Self-xating
at sheets include tiny hooks or barbs on the surface of the
mesh. These hooks imbed into the muscle fiber or tissue,
reducing the need for traditional xation. Partially resorbable
mesh has a component that dissolves into the body, typically
via hydrolysis, over time. This can allow the mesh to have lines
for visualization or a greater rigidity during the implantation and
then become a suppler, simpler implant long term.
Plugs. Plugs are exactly what the name implies. They are a
three-dimensional mesh structure used to plug a hernia defect.
Surgeons like to use plugs because they provide positive pressure
and help restore the position of the small intestine. In addition,
lling the hernia defect with material is another way to ensure
the repair is sufficient to prevent recurrence. Most plugs are
conical in nature.
The evolution of the plug is taking two paths. Some plugs are
moving toward lighter and more macro-porous material. The
second path is the movement toward incorporating resorbable
materials. This attribute gives surgeons the best of both worlds.
Many surgeons want a rigid plug for implantation. A plug is eas-
ier to handle and implant if its rigid. A rigid plug will also provide
positive pressure against the hernia content, restoring it to the
abdominal cavity. Ideally, plugs are rigid when rst implanted,
and then soften over time. The softness enhances the patients
quality of life by creating less scarring and pain. By using a re-
sorbable component, a few of the newest plugs have been able
to achieve this duality.
Looking to the future
Soft tissue repair continues to be a challenge for many
surgeons. As the population continues to age and become
more sedentary, tissue tone will continue to decline. As a result,
surgeons are facing more and more challenging repairs. Thankfully,
the industry continues to develop new and more cost effective
ways to meet the evolving challenges plaguing surgeons.
60 The ORConnection
2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Assure and Revive are registered trademarks of
Biomerix Corporation. C.A.B.S. Air and 4D DOME are registered trademarks of Cousin Biotech LLC. MotifMesh and VitaMesh are registered
trademarks of Proxy Biomedical Limited, LLC.
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COMPLETE SELECTION OF HERNIA MESH
Innovative, high-quality hernia
repair and reinforcement solutions
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CAUTI Prevention:
Cracking
the Case
S
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A
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CE Article
Cracking
the Case
by Margaret Falconio-West,
BSN, RN, APN/CNS, CWOCN, DAPWCA
Catheter-associated urinary tract infections (CAUTIs) are
the most common healthcare-associated infections (HAIs);
accounting for approximately 40 percent of all HAIs.
1
In an effort
to incentivize hospitals to lower CAUTI rates, the Centers for Medicare
& Medicaid Services (CMS) no longer reimburses hospitals for the costs
to treat CAUTI. In addition, several independent and government healthcare
agencies have developed guidelines and initiatives based on evidence-
based research to try to improve infection rates. Despite these efforts,
CAUTI rates remain high. But why?
It is not enough only to know the barriers to CAUTI prevention. Dr. Sanjay
Saint and colleagues at the University of Michigan Medical School
theorize that simply disseminating scientic evidence is often ineffec-
tive in changing clinical practice. Therefore, learning how to implement
these ndings is critically important to promoting high-quality care and
a safe health care environment.
1
Clinicians and facilities must have systems in place to ensure catheters
are placed only when necessary and removed in a timely fashion. But
the fact is most facilities do not. APICs Guide to the Elimination of
Catheter-Associated Urinary Tract Infections (CAUTIs) states: despite
signicant research on preventing UTI, bedside interventions such as
assessment for, and communication about, unnecessary urinary
catheters are inconsistently applied in healthcare settings.
2
Furthermore, survey data from a national random sample of non-federal
hospitals showed that 50 percent do not have a system for monitoring
which patients have urinary catheters and more than 70 percent do not
routinely monitor duration and discontinuation of urinary catheters.
1
Creating processes based upon evidence-based practices, educating
healthcare providers on how to implement those processes, and then
monitoring compliance and patient outcomes, is what will lead to
greater success in CAUTI prevention.
The Facts: What We Know About CAUTI Prevention
Widely disseminated research has shown two primary tenets regarding
CAUTI:
Too many catheters are placed without a valid clinical indication.
When they are inserted, catheters should be removed as soon
as clinically possible.
Patient Safety
Research showing too many catheters are placed:
Saint et al, 2005
3
Indwelling urinary catheters are placed in up to 25 percent of hospi-
talized patients and are a leading cause of hospital-acquired infection.
Physicians are often unaware that their patients have a urinary
catheter, and these forgottencatheters are frequently unnecessary.
In this study of 5,678 patients, a simple written reminder was imple-
mented to help healthcare professionals remember which hospital
patients had a urinary catheter. Two of the four wards were assigned
to the intervention group, and two served as controls. A research
nurse monitored the urethral catheter status of each patient daily.
Catheter use decreased 7.6 percent in the group using a reminder
system.
Saint, et al 2000
4
Use of indwelling urinary catheters is unnecessary in more than one-
third of patients. For this study, physicians and medical students were
given a list of their patients and asked if they knew which patients
had an indwelling urethral catheter as of the previous afternoon.
A total of 256 physicians and students completed the survey. Of 469
patients, 117 (25%) had an indwelling catheter. Overall, providers
were unaware of catheterization for 28 percent of their patients.
Catheter use was inappropriate in 31 percent of the 117 patients
Catheterization was more likely to be appropriate if respondents were
aware of the catheter.
Research showing catheters should be removed
as soon as clinically possible
Saint, et al, 2009
1
This study showed that duration of catheterization is the dominant
risk factor for hospital-acquired urinary tract infection.
Wald, et al 2008
5
CAUTI rates go up when catheters are left in too long. This retro-
spective cohort study, involving 2,965 acute care hospitals in the
United States, showed that 50 percent of patients who kept their
catheters in longer than two days after surgery were two times more
likely to develop CAUTI than patients who were catheterized two or
fewer days.
Strategies to Stop the CAUTI-Causing Culprits
As shown in the studies above, the factors that con-
tribute to CAUTI have been well-researched, but how do
facilities change their processes and get clinicians to
follow best practices in CAUTI prevention?
Dr. Bettina Knoll and colleagues at the Minneapolis Vet-
erans Affairs Medical Center achieved signicant reduc-
tions in Foley catheter use and Foley catheter order
documentation with a multi-faceted quality improvement
project implemented at the medical center over a period
of ve years. They used bundled interventions, including
multiple types of education, system redesign, rewards,
feedback and a dedicated Foley catheter nurse.
6
Survey data gathered in advance of the study identied
Foley catheter use in about 15 percent of hospital
patients at any time; 22 percent of those catheters
lacked an accepted indication and 17 percent lacked an
active provider order.
6
Educational posters and catheter order template.
Phase I began with placement of educational posters in
high-trafc areas, such as physician workrooms, nursing
lounges and staff restrooms. A Foley catheter order tem-
plate was also incorporated into the electronic medical
record system. The template allowed the clinician to
choose a catheter indication from a drop down menu or
ll in an indication of their own. There was also an auto-
matic 72-hour default stop date. When the stop date
approached, the template automatically generated an
electronic alert for the healthcare worker to remind the
provider currently about the patients catheter.
6
During a one-month hiatus following the rst phase of
the study, no interventions were preformed, other than
continued use of the electronic Foley catheter order tem-
plate, but without forwarding any electronic alerts.
6
The authors state that their observation that the preva-
lence of Foley catheter use exhibited a 33 percent rela-
tive decrease during phase I, then rebounded quickly to
baseline during the subsequent hiatus period, implies
that continuous use of multiple interventions was needed
for a sustained effect.
6
Making sure catheter alternatives are available. In
an editorial commentary on Knolls study, Jennifer Med-
dings and Sanjay Saint suggest taking this intervention
one step further by embedding reminders about appro-
priate alternatives to indwelling catheters within catheter
orders, and then having those alternatives (i.e., condom
catheters, bedside urinals and commodes) readily avail-
able for staff to use. They also recommend adding staff
training in the use of bladder ultrasound to evaluate
patients for urinary retention and investment in additional
employees to address the extra time and effort required
to care for patients with incontinence.
7
Saint and a team of researchers are conducting a simi-
lar study across the state of Michigan in conjunction with
the Michigan Health and Hospital Association (MHA)
Keystone Center for Patient Safety & Quality, involving
implementation of a CAUTI bundle that emphasizes:
continual assessment of patients with indwelling
catheters and catheter removal as soon as possible.
1
Saint and his team expect their study of hospitals
experiences with using the bladder bundle can be used
to develop effective strategies for implementing a range
of patient safety practices.
1
Alternatives to Foley Catheterization
Condom catheters
Suprapubic catheterization
Intermittent catheterization (with or without
bladder ultrasound)
Timed voiding
Bedside commode/urinal
Incontinence pads, disposable adult briefs
Specially designated Foley nurse. A novel and very
effective approach implemented at the VA Hospital was
employing a dedicated Foley nurse who was responsi-
ble for conducting daily hospital-wide surveys of Foley
catheter prevalence, indications and orders. If a patient
had a Foley catheter that was contraindicated, the Foley
nurse contacted the provider and advocated for its
removal. Similarly, if a Foley was indicated but lacked an
MEDLINES FOLEY INSERTAG
Reference
1 Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reduces urinary catheterization in
hospitalized patients. Jt Comm J Quality Patient Saf. 2005; 31(8): 455-462
2 Patient Safety Quality Measures for the Surgical Care Improvement Project (SCIP). Health Services Advisory Group.
Available at: http://qualitymeasures.ahrq.gov/content.aspx?f=rss&id=16275. Accessed December 7, 2010.
3 Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009. Centers for Disease Control and Prevention.
Available at: http://www.cdc.gov/hicpac/cauti/001_cauti.html. Accessed December 7, 2010.
2011 Medline Industries, Inc. Medline is a registered trademark and InserTag is a trademark of Medline Industries, Inc.
Despite SCIP Measure #9 recommending removal of
urinary catheters in surgical patients by postoperative day
one or two,
1
and CDC guidelines advising prompt removal
of catheters,
2
74 percent of hospitals do not keep track
of how long patients have catheters in place.
3
Medlines Foley InserTag is a sticker to be placed on each
catheter bag as part of the insertion procedure. It has
space to write when the catheter was placed in order
to minimize duration and encourage timely removal.
The InserTag is included with each Medline ERASE
CAUTI tray.
Medlines Foley InserTag. The one little sticker that can
make all the difference.
This easy documentation tool lets you know
exactly when your patients catheter was placed
Finally!
A way to know
when the catheter
was placed
Foley
InserTag
Launch the QR app
http://www.erasecauti.com/
1
2
3
LEARN MORE ABOUT THE ERASE CAUTI SYSTEM
active order, the Foley nurse entered an order into the
record and alerted the provider electronically for a sig-
nature.
6
The authors noted that the involvement of the Foley catheter
nurse seemed to have the greatest impact of any of the in-
terventions. Following the Foley catheter nurses departure,
the daily Foley catheter prevalence and percentage of Foleys
inserted without a provider order rose steadily, reaching 18
percent prevalence of catheters within about one year. (Foley
prevalence was 17 percent before the study began.)
6
Staff champions. Commenting further on the Knoll
study, Meddings and Saint commented that a common
theme in healthcare-acquired infection research is use of
dedicated team members or champions to serve as role
models for changes in clinical behavior. (Similar to the Foley
nurse.) These roles are often beyond that of a protocol
reinforcer and are particularly important when change
requires forms of sacrifice, such as additional work and
inconvenience.
6
Recommendations for future research. Despite the wide
array of available CAUTI research and emerging studies on
how to implement changes for improvement, there is much
we do not know. The 2009 CDC CAUTI prevention guide-
lines recommend further research in the following areas:
8
Catheter materials effectiveness of antimicrobial and
antiseptic-impregnated catheters
Appropriate catheter use in patients with incontinence
and postoperative patients
Antiseptics Use of antiseptic versus sterile solutions
for periurethral cleaning prior to catheter insertion; use
of antiseptics to prevent CAUTI
Alternatives to indwelling urethral catheters and
bag drainage
Use of a portable ultrasound in patients with low-urine
output to reduce unnecessary catheter insertions
Use of new prevention strategies such as bacterial
interference in patients requiring chronic catheterization
Spatial separation of patients with urinary catheters
to prevent transmission of pathogens colonizing
urinary drainage systems.
Ways to Ensure Catheters Are Discontinued
within 48 Hours After Surgery
Document the insertion date and time in the medical
record AND in a prominent place on the closed urinary
tubing system for nursing to nd easily.
Ask the surgeon to write an order in advance to
discontinue the catheter on postop day 1 or postop
day 2, unless there is a valid clinical reason to keep
the catheter in place.
5
Program visual monitors and cues into the
electronic medical record to remind nurses to
assess the patient every 24 hours for the
continued need for a catheter.
6
Designate a dedicated catheter nurse who collects
data on the prevalence of catheter use. He or she
will place catheter reminders on patients charts
and personally remind providers to remove catheters.
6
SAFER CATHETERIZATION
FOR KIDS
Sometimes, you just need a buddy. Buddy
the Brave lion cub is here to help your youngest
catheter patients. Along with some serious patient
(and parent) education resources, youll nd some
upbeat fun and even a bravery award sticker in
every tray.
But its more than just fun. Theres published evidence
that distraction helps children tolerate unpleasant
procedures better than adult reassurance does.
You trust Medline for clinical innovations, such as our
industry-leading catheter tray design. Now, we can be
your patients buddy, too.
Introducing Medlines new
Pediatric Catheter Tray. The
latest addition to the innovative
ERASE CAUTI product line.
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Pediatric
Catheter
Tray
Childrens
Activities
Bravery Sticker
1
2
3
LEARN MORE ABOUT MEDLINES ERASE CAUTI
PROGRAM AND ALTERNATIVES TO CATHETERIZATION
Launch the QR app
buddy-the-brave 2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
ERASE CAUTI and Buddy the Brave are trademarks of Medline Industries, Inc.

Does your catheter tray have these components?
Checklist to help clinicians to determine whether a
patient needs a catheter
Readily-available and easy-to-follow instructions
for use
Clear identication of latex content
Graphic presentation of what is included in the tray
Large sterile eld
Single-layer tray with components logically placed
Securement device included
Lubrication well to keep catheter from moving outside
the sterile eld
Sticker to identify time/date of placement of catheter
for compliance with SCIP INF-9
Patient education materials
What to look for when choosing
a urinary catheter tray
References
1. Saint S, Olmsted RN, Fakih MG, Kowalski CP, Watson SR, Sales AE, et al.
Translating health care-associated urinary tract infection prevention research
into practice via the bladder bundle. Jt Comm J Qual Patient Saf. 2009; 35(9):
449-455.
2. Guide to the Elimination of Catheter-Associated Urinary Tract Infections
(CAUTIs). APIC. Available at:
http://www.apic.org/Content/NavigationMenu/PracticeGuid-
ance/APICEliminationGuides/CAUTI_Guide_0609.pdf. Accessed July 15, 2011.
3. Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder
reduces urinary catheterization in hospitalized patients. Jt. Comm J Qual
Patient Saf. 2005;31(8):455-462.
4. Saint S, Wiese J, Amory JK, Bernstein ML, Patel UD, Zemencuk JK, et al.
Are physicians aware of which of their patients have indwelling catheters?
The American Journal of Medicine. 2000; 109(6):476-480.
5. Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter use in
the postoperative period: analysis of the National Surgical Infection Prevention
Project Data. Archives of Surgery. 2008; 143(6).
6. Knoll BM, Wright D, Ellingson L, Kraemer L, Patire R, Kuskowski MA, et al.
Reduction of inappropriate urinary catheter use at a Veteran Affairs Hospital
through a multifaceted quality improvement project. Clinical Infectious Diseases.
2011 Jun; 52(11):1283-1290.
7. Meddings J & Saint S. Disrupting the life cycle of the urinary catheter. Clinical
Infectious Diseases. 2011 Jun; 52(11):1291-1293.
8. Guideline for Prevention of Catheter-Associated Urinary Tract Infection 2009.
Available at: http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009nal.pdf.
Accessed July 15, 2011.
SAFER CATHETERIZATION
FOR KIDS
Childrens
Activities
APIC recommends the following strategies for success
in preventing CAUTI:
1. Incorporate prevention strategies into policies
and protocols
2. Adequately assess and document the need for urinary
catheters based on recognized indications*
3. Use catheters in operative patients only as necessary
in selected surgical procedures:
a. Patients undergoing urologic surgery or other surgery
on contiguous structures of the genitourinary tract
b. Anticipated prolonged duration of surgery (catheters
inserted for this reason should be removed in PACU)
c. Patients anticipated to receive large-volume infusions
or diuretics during surgery
d. Need for intraoperative monitoring of urinary output
e. Patients with urinary incontinence
4. Utilize the UTI prevention bundle
5. Remove urinary catheters as soon as possible (for
operative patients who have an indication for a catheter
preferably remove within 24 hours)
6. Implement systems to alert care providers to evaluate
the necessity for urinary catheters on a daily basis
7. Do no use catheters in patients and nursing home
patients for management of incontinence
8. Provide regular feedback to staff on process and/or
outcome measures
9. Implement quality improvement programs to reduce
catheter use and reduce the risk of urinary tract infections.
*Indications for the use of indwelling urethral catheters are
limited and include the following:
1. Urine output monitoring in critically ill patients
2. Management of acute urinary retention and urinary
obstruction
3. Assistance in pressure ulcer healing for incontinent
residents
4. As an exception, at patient request, to improve comfort
(i.e., end-of-life care)
APICs Guide to the Elimination of Catheter-Associated
Urinary Tract Infections (CAUTIs) is available at:
www.apic.org/Content/NavigationMenu/PracticeGuid-
ance/APICEliminationGuides/CAUTI_Guide_0609.pdf
The Centers for Disease Control and Prevention (CDC)
Guideline for Prevention of Catheter-Associated Urinary
Tract Infection 2009
The most recent CDC guidelines came out in 2009, and had
not been revised since 1981. New research and technolog-
ical advancements for preventing CAUTI prompted the revi-
sions. The document states: Our goal was to develop a
guideline based on a targeted systematic review of the best
available evidence, with explicit links between the evidence
and recommendations.
CAUTI Prevention
Guidelines
Summary of
To evaluate the available research on preventing CAUTI, the
CDC committee examined data addressing the following
three key questions:
1. Who should receive urinary catheters?
2. For those who may require urinary catheters, what
are the best practices?
3. What are the best practices for preventing CAUTI
associated with obstructed urinary catheters?
The CDC document provides the following priority recom-
mendations for appropriate catheter use:
Insert catheters only for appropriate indications (see chart
below) and leave in place only as long as needed.
- Avoid use of urinary catheters in patients and nursing
home residents for management of incontinence.
- For operative patients who have an indication for an
indwelling catheter (according to guidelines stated in the
chart below), remove the catheter as soon as possible
postoperatively, preferably within 24 hours, unless there
are appropriate indications for continued use.
The CDC guidelines state the following appropriate
indications for indwelling urethral catheter use:
Patient has acute urinary retention or bladder outlet
obstruction
Need for accurate measurements of urinary output in
critically ill patients
Perioperative use for selected surgical procedures:
Patients undergoing urologic surgery or other surgery
on contiguous structures of the genitourinary tract
Anticipated prolonged duration of surgery (catheters
inserted for this reason should be removed in PACU)
Patients anticipated to receive large-volume infusions
or diuretics during surgery
Need for intraoperative monitoring of urinary output
To assist in healing of open sacral or perineal wounds in
incontinent patients
Patient requires prolonged immobilization (e.g., potentially
unstable thoracic or lumbar spine, multiple traumatic injuries
such as pelvic fractures)
To improve comfort for end of life care if needed
The following are inappropriate uses of
indwelling catheters:
As a substitute for nursing care of the patient or resident
with incontinence
As a means of obtaining urine for culture or other diagnostic
tests when the patient can voluntarily void
For prolonged postoperative duration without appropriate
indications (e.g., structural repair of urethra or contiguous
structures, prolonged effect of epidural anesthesia, etc.)
For a complete copy of Guideline for Prevention of
Catheter-Associated Urinary Tract Infection 2009,
go to: www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguide-
line2009nal.pdf.
The Society for Healthcare Epidemiology of America (SHEA)
Strategies to Prevent Catheter-Associated Urinary Tract
Infections in Acute Care Hospitals
The SHEA guidelines recommend the following as the only
indications for the use of indwelling urinary catheters:
1. Perioperative use for selected surgical procedures
2. Urine output monitoring in critically ill patients
3. Management of acute urinary retention and urinary
obstruction
4. To help with the healing of pressure ulcers in patients
with incontinence
5. If a patient requests a catheter for personal comfort
The guidelines also recommend providing and implementing
written policies for catheter use, insertion and maintenance
and implementing a documentation system for recording the
indications for each catheter insertion, date and time of the
catheter insertion, the name of the individual placed the
catheter and the date and time the catheter is removed.
In addition, the guidelines emphasize consideration of other
methods, including condom catheters and in-and-out
catheterization when appropriate.
To access the entire SHEA document, visit:
www.wsha.org/les/82/HAI-Catheter-AssocUrinaryTract-
Strategies.pdf
CAUTI Prevention
Guidelines
Summary of
What did we do after
designing a revolutionary
new catheter tray system?
We found THREE more ways
to make it even better.
Were obsessed with engineering new and better
technology for healthcare workers. So after we
revolutionized the outdated Foley catheter tray with
a unique, one-layer system design, we immediately
turned our attention to addressing how we could
make it even easier to use. We studied how the
tray was being used in the eld. The result was
three more great improvements.
Combined with the previous innovative tray redesign
and comprehensive ERASE CAUTI education, these
three new features help to improve patient safety and
quality, while reducing avoidable costs associated with
waste and urinary tract infections.
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A checklist that ts better
in the medical record
The reformatted checklist is smaller, making
it easier to place in the paper chart or
attach to the electronic medical record.
Education youll want to present
to your patient
Theres nothing like the new Patient
Education Care Card. Designed to look
and feel like a Get Well Soon card, it
tells patients about catheterization so
they know you are providing them the
best care possible.
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Real photography on the outside
so you know exactly whats inside
A photo on the package helps identify the
contents of the kit, serves as an educational
tool for the clinician and can be used to
discuss the procedure with the patient.
Also, the label opens up to a booklet with
step-by-step instructions and helpful tips
for the clinician.
The Joint Commission
2012 National Patient Safety Goal: Catheter-
Associated Urinary Tract Infection (CAUTI)
The following is the one new National Patient Safety Goal
for 2012 (NPSG.07.06.01) approved by the Joint Commis-
sion: implement evidence-based practices to prevent
indwelling catheter-associated urinary tract infections
(CAUTI).
Additional information about the Joint Commissions
National Patient Safety Goals is available at www.jointcom-
mission.org.
The Surgical Care Improvement Project (SCIP)
SCIP Inf-9 recommends that a urinary catheter placed
during surgery should be removed on Postoperative Day 1
(POD 1) or Postoperative Day 2 (POD 2), with the day of sur-
gery being day zero.
This SCIP measure is leading clinicians to think about how
to identify which surgical procedures have a valid clinical
indication for insertion of a Foley catheter and to eliminate
the insertions in procedures with no valid clinical indication.
This represents a major change in a practice that has been
considered routine for many years. The catheter might not
be needed in the rst place, and if left in too long, can lead
to a preventable hospital-acquired infection.
Whats needed to improve compliance? A method to keep
track of exactly when the catheter was inserted and when
the procedure was completed to ensure that catheterization
is discontinued before Postoperative Day 2 ends.
For more information about SCIP measures, go to:
www.qualitynet.org.
Designate a dedicated
catheter nurse who
collects data on the
prevalence of catheters,
places catheter reminders
on patients charts and
personally reminds
providers to remove
catheters.
True/False
1. Simply disseminating scientic evidence is often
effective in changing clinical practice. T F
2. Too many catheters are placed without a valid
clinical indication. T F
3. Condom catheters are recommended
alternatives to urinary catheterization. T F
4. Implementing evidence-based practices to prevent
indwelling catheter-associated urinary tract infections
(CAUTI) is one of ve Joint Commission National Patient
Safety Goals for 2012. T F
5. The best way to ensure catheters are
discontinued within 48 hours after surgery is to
document the insertion date and time in the
medical record. T F
Multiple Choice
6. Guidelines published by APIC, the CDC and __________
indicate that use of an indwelling urinary catheter is
appropriate in individuals with pressure ulcers in order
to help them heal.
a. SCIP
b. Joint Commission
c. FDA
d. SHEA
Visit www.medlineuniversity.com and login or create
an account. Choose your course to take the test and
receive 1 FREE CE credit.
7. According to the Knoll study, the most effective
intervention for making sure catheters were
removed in a timely fashion was use of a
____________________________.
a. Foley catheter nurse
b. Reminder system in the electronic medical record
c. Silver-coated catheter
d. None of the above
8. Survey data from a national random sample of
non-federal hospitals showed that ____ percent
do not have a system for monitoring which
patients have urinary catheters.
a. 26
b. 10
c. 78
d. 50
9. According to a 2000 study by Saint et al., use of
indwelling urinary catheters is unnecessary in
more than _________ of patients.
a. one-half
b. one-third
c. two-thirds
d. one quarter
10. A 2008 study by Wald et al showed that ____
percent of patients who kept their catheters in
longer than two days after surgery were two
times more likely to develop CAUTI.
a. 32
b. 50
c. 85
d. 12
Courses approved for continuing education by the Florida Board
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CAUTI Prevention: Cracking the Case
PREPARING YOUR HOSPITAL FOR
SUCCESSFUL
QUALITY IMPROVEMENT
With the Partnership for Patients sponsored by the
Department of Health and Human Services
Preparing your organization to achieve widespread and sustainable improve-
ment is its own challenge. Here are some steps hospitals across the country
have found helpful in getting ready to improve care.
76 The ORConnection
Join the Partnership for Patients. Dont forget the rst step!
The Partnership for Patients brings together leaders of major
hospitals, employers, physicians, nurses, and patient advo-
cates along with state and federal governments in a shared
effort to make hospital care safer, more reliable, and less costly.
Go to www.healthcare.gov/center/programs/partnership/-
join/index.html and click on the green box to join.
The two goals of the Partnership for Patients are:
Keeping patients from getting injured or sicker. Accidents
happen, and too often patients in hospitals experience pre-
ventable harms. The initiative seeks to increase efforts to pre-
vent harm to patients in hospitals. By the end of 2013,
preventable hospital-acquired conditions would decrease by
40% compared to 2010.
Helping patients heal without complication. Patients are
often at their most vulnerable when leaving the hospital to con-
tinue healing at home, in an assisted living facility, or in another
care setting. The initiative seeks to improve continuity and
effectiveness of care during transitions from one care setting
to another and decrease preventable hospital readmissions
within 30 days of discharge. By the end of 2013, preventable
complications during a transition from one care setting to
another would be decreased so that all hospital readmissions
would be reduced by 20% compared to 2010.
Achieving these goals will save lives and prevent injuries to mil-
lions of Americans, and has the potential to save up to $35
billion dollars across the health care system, including up to
$10 billion in Medicare savings, over the next three years. Over
the next ten years, it could reduce costs to Medicare by about
Patient Safety
Introducing New
Continuing Education
for Materials Managers
Visit Medline University
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Implementing Incentive Programs to Drive
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$50 billion and result in billions more in Medicaid savings. This
will help put our nation on the path toward a more sustainable
health care system.
Get your board and leaders committed. Strong support
and attention from leadership is essential to organization-wide
improvement. Make sure that safety and quality is a priority for
ofcers and board members -- for example, make an update
on improvement the rst agenda item for board meetings, and
assign a lead sponsor to each adverse event effort to quickly
address administrative barriers that arise. Many organizations
have benetted from involving the board in Patient Safety
Leadership WalkRounds.
Make your CFO a quality champion. Preventable adverse
events and readmissions contribute huge costs to the health
care system overall, a portion of which is borne by hospitals.
Medicare payment changes that are part of the Affordable
Care Act and other legislation chart a course for dramatic
changes in how hospitals will be paid in the coming years.
Through reimbursement incentives and value-based purchas-
ing, hospitals will have a substantial portion of their Medicare
payments tied directly to their safety and other measures of
the quality of care they deliver. Private employers and health
plans increasingly are also using an array of market-based
incentives, including payments, to promote safety and higher
quality. Quality should now be on the agenda of all hospital
CFOs, and the support of improvement initiatives should be
given the same priority and attention as other initiatives critical
to the bottom line of your organization. As has been well
shown in other industries, strategies that improve quality also
improve productivity and efciency.
Energize your staff by making the Partnership for
Patients your own. This initiative is voluntary. Hospitals
that choose to join should feel ownership of their work,
and be proud of it. To help nurture this energy, think about
how to frame the Partnership for Patients work as an
extension of your organizations mission and culture, and
of existing quality improvement work already underway.
That is, make it your own.
Create an organization-wide mandate, with public
goals and deadlines. Create energy and urgency by
dening success and identifying clear goals and timelines.
Goals can be oriented around processes (achieve 95%
reliability for medication reconciliation by 2013) or outcomes
(no preventable harm to patients in 2013) but they
should be ambitious and publicly stated.
Identify staff champions. When tackling safety and
quality across the organization, the credibility of the
intervention is often critical. Staff will want to know, Will
this really improve outcomes for my patients? Getting
respected staff members from several key departments
involved early as advocateschampionsfor an
improvement project is a great way to address these types
of questions, and provide the credibility needed to get
others on board and excited about the work.
Identify community champions. Readmissions can
often be prevented if your patients and their caregivers
have good support at home when they are discharged
from your hospital. Through supportive services, coaching,
and care management, area agencies on aging, home
care agencies and other community-based organizations
can help your patients transition successfully.
80 The ORConnection
Form improvement teams for each adverse event.
Where teams dont already exist, assign key staff to begin
laying the groundwork for how your organization would like
to address a particular adverse event, and how care
transitions might be improved. These teams should have
sponsors from senior management and middle management,
and begin identifying candidate interventions and measures
that would make sense in the context of your organization.
One of the most useful things these teams can do is begin
to reach out to other hospitals that have already begun
working in similar areas, especially similar hospitals that
have had success and can offer highly relevant and
credible advice.
Assess and develop the basic improvement skills
and knowledge of staff. No matter what projects your
organization undertakes, an awareness of basic
improvement principles and techniques will go a long
way to making those efforts successful. Many resources
are currently available to help organizations assess and
improve staff knowledge in this area, and the Partnership
for Patients will make even more available.
Set expectations for a fast-moving, iterative work
environment. Once an intervention is identied, one of
the greatest temptations is to try to get the implementation
perfect on the rst try. Unfortunately, this is almost always
impossible, and the months spent in planning meetings
tweaking a form or process often turn out to be largely
wasted. Instead, set expectations that improvement will
be done using quick-cycle iterations in which new ideas
are eshed out, tested, studied, rened, and retested on
a time scale of days, not months.
Prepare to make improvement measure results
available internally and with a quick turnaround.
The hospitals that have achieved the most success with
improvement often have something in common: They
compile their measure results quickly and report them
back to improvement team members. If you are piloting
a new process this week, you want to know by Friday,
not next month or next quarter, whether it improved
reliability. To accomplish this kind of turnaround, measures
and data collection activities must be relatively simple,
and time must be set aside regularly to compile and
communicate results.
Source: U.S. Department of Health & Human Services
www.healthcare.gov/center/programs/partnership/safer/prepare.html
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82 The ORConnection
ASGE, SHEA
Issue New
Guidelines on
Reprocessing
Flexible
Gastrointestinal
Endoscopes
In June 2011 the American Society for Gastrointestinal Endoscopy
(ASGE) and the Society for Healthcare Epidemiology of America
(SHEA) collaborated with multiple organizations and industry
experts to update the 2003 guidelines on reprocessing exible
gastrointestinal endoscopes.
Endoscopic procedures have become very common in the United States, with more than
20 million GI procedures routinely performed each year. To date, all published occurrences
of pathogen transmission related to GI endoscopy have been associated with failure to
follow established cleaning and disinfection/sterilization guidelines or use of defective
equipment. Despite strong data regarding the safety of endoscope reprocessing, clini-
cians concerns about the potential for pathogen transmission during endoscopy have
raised questions about the best methods for disinfection or sterilization of these devices
between patient uses. Since the 2003 guideline, high-level disinfectants, automated
reprocessing machines, endoscopes, and endoscopic accessories have all evolved; how-
ever, the efcacy of decontamination and high-level disinfection is unchanged and the prin-
ciples guiding both remain valid.
1
Prior to the performance of a procedure, an endoscope must be carefully cleaned and dis-
infected according to guidelines published by the American Society for Gastrointestinal
Endoscopy, which have been endorsed by every major medical and nursing association
dealing with endoscopy and infection control.
Mechanical cleaning: The operating channels and external portions of the endoscope
are washed thoroughly, wiped with special detergents that contain enzymes, and
cleaned with brushes. Studies have shown that these steps alone can eliminate
potentially harmful viruses and other microbes from an endoscope.
However, much more is done before the endoscope is considered ready for use.
Disinfection: Next, the endoscope is soaked continuously for an appropriate time
period with one of several FDA-approved liquid chemicals that destroy
microorganisms, including the AIDS virus, hepatitis viruses, and potentially harmful
bacteria.
Post-processing: The instrument is rinsed with water to remove residual chemicals,
subjected to a nal alcohol rinse, and the internal channels dried with forced air.
In addition, the endoscopy unit must train staff involved in endoscopic reprocessing, which
is mandatory for quality assurance and for effective infection control. General infection con-
trol principles should be adhered to at the endoscopy unit.
2
by Lorri A. Downs, RN, BSN, MS, CIC
Prior to the performance of a procedure, an endoscope
must be carefully cleaned and disinfected
Patient Safety
84 The ORConnection
The key reprocessing updates for 2011
are summarized below:
1. Guidelines emphasize complete cleaning of endoscopes,
removing protein, tissue and debris then application of
high level chemical disinfectants. Following manufacturing
recommendations for device-specic reprocessing
is encouraged. A collaborative study reported that 24%
of patient ready endoscopes were culture positive and
these were associated with a number of fundamental
errors in the disinfection process.
3
2. Lapses in hand hygiene, reprocessing tubing with one-way
valves attached and endoscopic channels have been at the
core of infection transmission.
3
3. Ensure biopsy forceps are sterilized prior to use.
3
4. Appropriately clean all channels during reprocessing.
3
Unresolved issues:
3
1. Length of time endoscopes can be stored (hang time)
between use. AORN is recommending 5 days and APIC will
go up to 7 days of storage before endoscopes must be re
processed.
2. The length of time between replacement is undetermined for:
water bottles, tubing for insufations of air, lens wash water,
waste vacuum canisters and suction tubing replacement.
AORN is recommending changing each after every
procedure.
3. Endoscope durability and longevity are not fully understood
and warrant further research.
For a complete copy of the updated guidelines,
go to http://giejournal.org.
References
1 ASGE and SHEA issue updated multisociety guideline on reprocessing exible
gastrointestinal endoscopes [news release]. Oakbrook, IL: American Society for
Gastrointestinal Endoscopy; June 1, 2011. http://www.eurekalert.org/pub_re-
leases/2011-06/asfg-aas060111.php. Accessed June 20, 2011.
2. Infection Control and Endoscopy: Frequently Asked Questions from ASGE. American
Society for Gastrointestinal Endoscopy website. Available at:
http://www.asge.org/PressroomIndex.aspx?id=6878. Accessed June 20, 2011.
3. Gastrointestinal Endoscopy. Multi-Society Guideline on Reprocessing Flexible GI endo-
scopes: 2011. Available at: http://giejournal.org/. Accessed June 21, 2011.
About the author
Lorri Downs, RN, BSN, MS, CIC is a board-
certied infection preventionist and vice president
of infection prevention for Medline Industries, Inc.
She has a diverse portfolio of more than 25 years
in nursing. Her expertise focuses on infection pre-
vention surveillance at large acute care organiza-
tions, plus ambulatory and public health settings.
Lorri has developed hospital infection control
programs and local emergency preparedness plans, and she has lec-
tured on various infection prevention topics.
A collaborative study
reported that 24% of
patient ready endoscopes
were culture positive and
these were associated
with a number of
fundamental errors
in the disinfection
process.
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86 The ORConnection
W M A Z L K P E J S U O
Q R E G H Y D O T U A X
F R E J P L N A U T E U
M X R J F Z R G E E M
These two photos might
seem identical, but if you
look closely, the bottom
one is a little different in six
places. When you nd a
difference, draw a straight
line connecting the center of
the area in the top photo to
its changed counterpart in
the bottom photo. (Use a
ruler for best results.) Each
line you draw will cross out
one column of letters. When
youve found all six differ-
ences, the remaining letters,
read in order, left to right and
row by row, will give you an
important safety message.
ANSWER:
________________________
________________________
________________________
Answer on next page.
Patient Safety Mystery Message
Whats Wrong with These Pictures?
Special Feature
Patient Safety Mystery Message Answer
Differences, from left: 1) glove is shorter;
2) catheter tip is rotated; 3) vial lid has
changed color; 4) towelette now has a
numeral 2 on it; 5) glove box now has
an M on it; 6) hand image is missing
from glove box. The message is:
Make sure you are latex-free.
The clinician in the photos takes care to
wear latex-free gloves, but she is insert-
ing a latex catheter. Be sure to check the
catheters at your facility. Are they really
latex-free?
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Time Management: How to
STRETCH
Your Time Rubber Band
Time is your second most precious resource. Its the only resource you
cant buy, borrow, rent or produce. Its preciousness exists because time
is the only commodity that is required for everything we do. Unlike most
things we deal with, time is totally perishable and absolutely irreplaceable.
In fact the only thing that is more precious than time is our health. Unfor-
tunately, most of us are equally careless with both.
Wolf J. Rinke, PhD, RD, CSP
88 The ORConnection
This article will help you manage your time more effectively.
Come to think of it, time management is a misnomer. Each of
us is provided with 24 hours every day. No matter how well you
manage it, it still only adds up to 24 hours. Instead of manag-
ing time, we manage and prioritize the activities in those 24
hours. And we get everything done that we perceive to be
important. (Read that again, it is a critical concept.) Before you
nix this idea, please pause a moment, reflect and recall the
one activity that is the most important to you. On the per-
sonal side it may be being with your family, football or garden-
ing. On the professional side it may be making more money,
being recognized by your peers or getting promoted. Now think
back: how often have you been unable to devote enough time
to whatever it is that is the most important to you? I bet it doesnt
happen very often, does it? In other words, most people make
time for all the things they consider important. In other words,
time is like a rubber band.
Heres how to stretch your time rubber band and help you get
the most out of every 24 hours:
Record Your Time
Before you can make more time, you must rst gure out how
you are currently spending it by keeping a time log for at least
three to ve days. Do this as soon as possible after you have
completed a particular task. An easy way to do this is to record
your activities on your calendarelectronic or paper, in half-
hour increments. (My Time Management CPE program has
an easy-to-use form you can use for this purpose
http://www.wolfrinke.com/CEFILES/cenutr.html#C196.)
Analyze Your Time Expenditures
Now ask several questions of the data you have collected. The
rst and most important: What would happen if I did not do this
task or activity at all? If the answer is nothing, stop doing it!
(Just this one step will save you lots of time!) If not sure, gure
out how what you are currently doing originated. Then go back
and nd out whether the originator wants you to continue, or
if it is still required in a current regulation. Note the words are
required and current, not nice to have or because we always
have done it that way, or even it is in one of our standard
operating procedures. If you cant gure out how the practice
originated, and you dont see any positive impact on the
bottom line, quit doing it. If it is really important, someone will
ask about it.
Look for Time Patterns
Next look for patterns in your use of time so that you can
chunk your time. Lets assume that your 3- to 5-day time
record reveals that you are faced with constant interruptions
Caring for Yourself
Improving Quality of Care Based on CMS Guidelines 90
ERASE CAUTI
SIMPLIFIED
TO SAVE YOU TIME
Launch the QR app
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from email, telephone, and a wide variety of administrative func-
tions. Combine these. For example, only answer emails and
other routine calls during specied times of the day.
Similarly, routine administrative functions should be handled
only during a certain period of the day ideally when you tend
to be least productive. Obviously, you must still take care of the
true emergencies, which should be analyzed, especially the re-
current ones. The reason is that frequent crises are an indica-
tion of sloppy management. Processes must be put into place
to routinize them so that someone other than you can handle
them.
Take Advantage of the 80-20 Rule
Your next step is to categorize your time to gure out whether
you spend most of your time on trivial tasksthe irrelevant
manyor on the important biggiesthe critical few. The
Pareto principle, better known as the 80-20 rule, maintains that
80 percent of the important results are accomplished in 20 per-
cent of the time. This phenomenon exists because work falls
into two major categories, the critical few and the irrelevant
many. The irrelevant many include all the mundane things such
as lling out forms, attending meetings, answering emails and
so on, which will devour about 80 percent of your time. The
time that you have left, about 20 percent, can be devoted to the
critical few. These will determine whether your hospital will be
a leader in the industry and whether you will be promoted or get
a bonus. They include such things as taking care of patients,
interviewing new employees, cost-cutting, system develop-
ment, etc. I call these winning results areas (WRAs). When you
allocate more time to the critical few, you will realize massive
productivity increases. For example, by allocating just one per-
cent more of your time to the critical few, you will realize an
increase of four percent in the WRAs. That represents a 400
percent return on your time investment. Bingo!
Set Goals and Priorities
Goals can serve as a driving force in your life, continually pulling
you in the right direction. Basically, a person without a goal is
like a ship without a rudder. Likewise, an organization without
clearly defined goals, stated in a prioritized fashion, is an
organization that will not be successful. The irony is that many
of us work in organizations that have very elaborate goals and
objectivesin many cases, we are the ones who developed
themyet most of us do not have similar goals for our
personal lives and careers. (For specics read my popular
How to Maximize Professional Potential CPE program--
www.wolfrinke.com/CEFILES/cepd.html#C187.) Because
effective goal-setting is critical, I would like to briey share a bit
of management folklore with you that has come to be called
the $25,000 idea.
A simple tool to prioritize your life. Folklore has it that an
efciency consultant by the name of Ivy Lee was meeting with
the president of a steel mill. The president, Charles Schwab,
wanted to nd out how to get more done within available time,
and he was willing to pay anything within reason for such
advice. Lee said that he could help him increase his efciency
by at least 50% provided he could have about 20 minutes of
his time.
After Schwab consented, Lee gave him a blank piece of paper
and told him to write down the six most important things he
wanted to accomplish tomorrow. Schwab thought about it and
completed the task in about three minutes. Then Lee instructed
him to order these things from most important to least impor-
tant. Now Schwab was instructed to keep the list until the fol-
lowing morning, at which time he was asked to look at the rst
item and to start working on it until it was completed. After that
he was told to work on task number two and so on until the
end of the day. Lee further advised Schwab not to worry about
the tasks that he could not get done, since they didnt matter,
because they would not have gotten done anyway. Then
Schwab was asked to repeat this process every working day.
Lee also asked Schwab to have his employees try this system
and, if it worked, to send him a check for whatever the idea
was worth to him.
92 The ORConnection
After several months Lee received a check for $25,000 and a
letter in which Schwab said that it was one of the most prof-
itable ideas he had ever been taught. It is further reputed that
the consistent application of this strategy helped turn this small
steel mill into Bethlehem Steel. The moral of this story relates to
what it takes to eat an elephant.
How to eat an elephant. Im sure youve heard that if you
want to eat an elephant, you have to take one bite at a time.
Your job is probably just like that proverbial elephant, so if you
want to master itinstead of it mastering youyou have to
have goals, prioritize them and take each one in turn, just like
Lee said. These two strategies are effective because they not
only provide you with a sense of direction, but also provide you
with a focus and a sense of accomplishment. Many healthcare
professionals tend to diminish their effectiveness because they
come to work without a vision. They are there to work on the
irrelevant many, never asking themselves, What is the one
thing I can accomplish today that will make a big difference to
this hospital or in my life?
One More Time with Feeling
Which strategy you use to stretch your time rubber band is not
important, provided it forces you to work on the critical few
and it disciplines you to nish one task before starting another.
You see, how many projects you start doesnt count; the num-
ber you nish, even if it is only one important one, does! In fact,
being busy or working long hours doesnt count either; results,
especially the WRAs, do! So visualize your prioritized goals, and
work them tenaciously until they are done. Never worry about
all the things you are not doing, or all the things you were un-
able to accomplish yesterday, because yesterday is gone and
all the fretting in the world wont make it come back.
Take Advantage of the Three-Minute Rule
I suggest you use these strategies as guidelines and set up a
system that works for you. Note I said guidelines because of
a recent experience with one of my coachees. She had just n-
ished reading my time management CPE program
(http://www.wolfrinke.com/CEFILES/cepd.html#C198).and
was trying to abide by the rules I had prescribed. Proud of her
success, she was telling me how she had told someone that
she would call him back with an answer, so that she could con-
tinue working on a major task. I asked her what the interruption
was about and found out that she could have quickly resolved
it. When asked why she had not taken care of it right away, or
at least had offered to reply with an email later, she said she
wanted to chunk her time so that she could concentrate on
the major task at hand and be more productive.
In this case the operation was a success, but the patient
died. By the time she would nally be able to reconnect with
the caller (you know how long it can take to play telephone tag)
my coachee would have used up far more time than she saved
by chunking her time. In other words, the literal application of
any theory seldom works unless you tailor it to yourself and to
the situation, and then superimpose some common sense. To
help my coachee I shared the three-minute rule with her: Once
interrupted, do anything on the spot, provided it can be ac-
complished in less than three minutes. Lets face it, youve been
interrupted. So get it over with. You will nd that even though it
may violate one of the other rules, it will save you lots of time in
the long run. The moral of this story is that you must always
look at the bottom line and ask: Which is the most cost-
effective strategy over the long run?
2011 Wolf J. Rinke
Dr. Wolf J. Rinke, RD, CSP is a keynote
speaker, seminar leader, management con-
sultant, executive coach and editor of the
free electronic newsletter Read and Grow
Rich, available at www.easyCPEcredits.com.
In addition he has authored numerous CDs,
DVDs and books including Make It a Win-
ning Life: Success Strategies for Life, Love
and Business, Winning Management: 6 Fail-
Safe Strategies for Building High-Performance Organizations and
Dont Oil the Squeaky Wheel and 19 Other Contrarian Ways to
Improve Your Leadership Effectiveness; available at www.Wolf-
Rinke.com. His company also produces a wide variety of quality
pre-approved continuing professional education (CPE) self-study
courses, avai l abl e at www.easyCPEcredi ts.com. Reach
hi m at Wol fRinke@aol.com.
Yes, Theyre Genuine.
Only Medlines Pink Pearl gloves combine
aloe, nitrile and breast cancer awareness.
Medline is a registered trademark
and Pink Pearl is a trademark of
Medline Industries, Inc.
Launch the QR app
http://pinkglovedance.com/
1
2
3
LEARN MORE ABOUT THE PINK GLOVE DANCE
AND SUPPORT BREAST CANCER AWARENESS
94 The ORConnection
In Celebration of
Breast Cancer
Awareness
TouringArtExhibit
SpotlightsSurvivors
andFamilyMembers
Most people can say they know someone who has been
diagnosed with breast or ovarian cancer. Women
everywhere face the fear of diagnosis every year as they
have their annual mammograms and physician
examinations. A new national traveling art exhibit, titled
Voices and Visions, Standing on the Bridge between Health
and Disease gives voice to those who have been touched
by womens health, who may live in fear, or who are
survivors of womens cancers.
Sponsored by Medline Industries, Inc., the company that
produced the Pink Glove Dance video, the exhibit made its
rst stop earlier this spring at the Lakewood Center for the
Arts in Lake Oswego, Ore., located just outside of Portland.
Fittingly, this inaugural exhibit was held in partnership
with Portland-based Providence St. Vincent Medical
Center, the hospital that was featured in the rst Pink Glove
Dance video.
The exhibit features more than 27 artists and 45 pieces of
art. All the pieces have been produced by artists who have
been dramatically affected by womens cancers.
The art exhibit is an extension of our breast cancer aware-
ness campaign with the goal of empowering those who
live on that bridge between health and disease, said Sue
MacInnes, Medlines chief marketing ofcer. Similar to our
message with the Pink Glove Dance, our hope with the art
exhibit is to reach people in a creative and interesting way to
get them engaged and talking about breast cancer.
The exhibit also features statements of women who have
undergone breast or ovarian surgeries. Whether elective
...as I stood before the blank canvas, I asked myself how I can begin the
process of detaching as I face another elective life saving surgery.
- Caren Helene Rudman
for prophylactic reasons, or recommended because of a
positive diagnosis, women who undergo surgeries endure
life changes, both physical and emotional.
About the Artists
In one way or another, all of the artists have been
dramatically affected by womens cancers. Some are sur-
vivors; some have had family members with the disease and
some are carriers of the BRCA1 gene linked to the
development of hereditary breast and ovarian cancer. One
photographer, for example, had an 18-year-old cancer
patient ask him to photograph her. Another male artist took
care of his mother through multiple cancers, including
ovarian. Several artists have sisters who had cancer, and
others had mothers with the disease.
The Curator
Caren Helene Rudman is an artist who works with mixed
media, photography and writing. After learning she carried
the BRCA1 gene, a hereditary increased risk for breast and
ovarian cancers, she began to delve into genetics. She has
become part of a coalition of woman who are passionate
about educating people on the risk of hereditary cancers
and the power of taking control of our own bodies. Recently,
she was invited to participate in a project, Heroes in the
Fight Against Breast Cancer, where she and 14 other
devoted women were honored by the governor of Illinois.
The exhibit is scheduled for stops late this fall at Skokie
Hospital in Skokie, IL and Floyd Medical Center in
Rome, GA.
Paintings by Caren Helene Rudman
Special Feature
Remember...
Order your pink gloves
and other pink products
now for National Breast
Cancer month! Visit
www.medline.com
Pink merchandise from Medline helps support
the National Breast Cancer Foundation.

Get Your Pink On
Enter the 2011 Pink Glove Dance
Competition for Breast Cancer Awareness

To enter, scan the QR code
or visit PinkGloveDance.com
Team up with Medline for
awareness, prizes and fun
Gather your dancers
Build excitement within your community
no talent necessary!
Make and submit your video
Get ready you may go viral
before you know it
1
2
3
Be Part of the Movement
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F
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o
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Chicago Healthcare
Worker and Survivor Shoot
Tallahassee
Memorial
Healthcare
HCA Johnston
Willis Hospital
Providence
St. Vincent's
in Portland, OR
S
T
A
R

S
E
A
R
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Isabella Geriatric
Center in NYC
Halifax Nova Scotia -
Capital Health
Tallahassee Memorial
Healthcare
Providence
St. Vincent's in
Portland, OR
IU Health in
Indianapolis,
Indiana
Special Feature

Win Donations to Your Favorite
Breast Cancer Charity*
First Place: $10,000
Second Place: $5,000
Third Place: $2,000
Contest Key Dates
August 1 Contest begins
September 26 Postmarked deadline
for video submissions
October 3 Voting begins
October 28 Winners announced
* Subject to Medline review and approval.
The search is on for the best Pink Glove Dance video.
A national online competition kicked off August 1 inviting
hospitals, nursing homes, schools really anyone who
wants to show off their creative air and passion for
breast cancer awareness and prevention, to produce
and submit their own Pink Glove Dance video. The
competition is sponsored by Medline Industries, Inc.,
the creator of the YouTube
sensation Pink Glove

Dance and makers of the pink gloves.
Submissions will be posted on the internet beginning
October 3, and the public is invited to vote on their
favorite. For complete rules and more information on
the competition, go to pinkglovedance.com.
The original Pink Glove Dance video premiered in
November 2009 and featured 200 Portland, Ore.
hospital workers wearing pink gloves and dancing in
support of breast cancer awareness and prevention.
Today the video has more than 13 million views on
YouTube and has been the inspiration behind hundreds
of pink glove dance videos and breast cancer
awareness events across the country.
How do I enter?
Go to pinkglovedance.com for ofcial rules all the
information you need to enter and produce and promote
your video.
What can I win?
The top three winners will receive a donation in their
name to the breast cancer charity of their choice, such
as the National Breast Cancer Foundation. The winners
will be announced October 28 onpinkglovedance.com.
What songs can I use?
You can use only one of the following songs, but what
a great choice you have. The following artists have gen-
erously approved the use of their song for the contest:
1 Soak up the Sun by Sheryl Crow
2 Down by Jay Sean (song used in the original Pink
Glove Dance video)
3 You Wont Dance Alone by the Best Day Ever
(song from the Pink Glove Dance sequel)
4 Evacuate the Dance Floor by Cascada
5 Firework by Katy Perry
6 Raise Your Glass by Pink
7 Till the World Ends by Britney Spears
Tallahassee
Memorial
Healthcare
San Fransisco
Survivor Shoot

Tips for Cleaning
Fruits and Vegetables
Whats Prowling
in Your Produce?
Its important to eat a variety of fresh fruits and vegetables. But
beware of fertilizer residue resting on your raspberries. Or bac-
teria lurking in your lettuce.
Federal health ofcials estimate that nearly 48 million people are
sickened by food contaminated with harmful bacteria each year,
and some of the causes might surprise you.
Although most people know animal products must be handled
carefully to prevent spoilage, many dont realize that fruits and
veggies can also be the culprits in outbreaks of foodborne illness.
In the last year, the United States has had several large out-
breaks of illness caused by contaminated fruits and vegeta-
blesincluding spinach, tomatoes, peppers and strawberries.
Glenda Lewis, an expert on foodborne illness with the Food and
Drug Administration, says produce can be contaminated in
many ways. During the growing phase, fruits and veggies may
be contaminated by the soil, water, or the fertilizer. After its
harvested, it passes through many hands, increasing the con-
tamination risk. Contamination can also occur once the produce
has been purchased, during the food prep or even through
inadequate storage. With so many sources from whence con-
tamination can occur, safely preparing your produce before eating
is especially important.
FDA says to choose produce that isnt bruised or damaged, and
make sure that pre-cut itemssuch as bags of lettuce or
watermelon slicesare either refrigerated or on ice both in the
store and at home. In addition, follow these recommendations:
Wash your hands for 20 seconds with warm water
and soap before and after preparing fresh produce.
Cut away any damaged or bruised areas before
preparing and eating.
Gently rub produce while holding under plain running
water. Theres no need to use soap or a produce wash.
Wash produce BEFORE you peel it so dirt and bacteria
arent transferred from the knife onto the fruit or veggie.
Use a vegetable brush to scrub rm produce, such as
melons and cucumbers.
Dry produce with a clean cloth or paper towel to further
reduce bacteria that may be present.
Throw away the outermost leaves of a head of lettuce
or cabbage.
Lewis says you should store perishable produce in the refriger-
ator at 40 degrees or below.
Because cooking food kills harmful bacteria, raw veggies and
fruits carry the biggest risk of contamination. Lewis says to steer
clear of raw sprouts, which are often served on salads, wraps,
sandwiches, and Asian food.
Source: U.S. Food and Drug Administration
Find this and other Consumer Updates at http://www.fda.gov/ForConsumers/ConsumerUpdates
During the growing phase, fruits and veggies may be
contaminated by the soil, water, or the fertilizer.
Caring for Yourself
Healthy Eating
1 (5 oz.) bag mixed spring salad greens
2 oz. crumbled blue cheese
1 orange, peeled and sectioned
pint fresh strawberries, quartered
Sweet and Spicy Pecan Topping:
cup sugar
1 cup warm water
1 cup pecan halves
2 tablespoons sugar
1 tablespoon chili powder
1
/8 teaspoon ground red pepper
Balsamic Vinaigrette Dressing:
cup balsamic vinegar
1 cup olive oil
3 tablespoons Dijon mustard
3 tablespoons honey
2 garlic cloves, minced
2 small shallots, minced
teaspoon salt
teaspoon pepper
Directions:
For ease, make the sweet and spicy pecans
and balsamic vinaigrette ahead of time.
To make pecan topping: Stir together cup
sugar and warm water until sugar dissolves.
Add pecans; soak 10 minutes. Drain; discard
liquid. Combine 2 tablespoons sugar, chili
powder and red pepper. Add pecans; toss to
coat. Place pecans in a single layer on a
lightly greased baking sheet. Bake at 350 de-
grees for 10 minutes or until golden brown,
stirring twice.
To make dressing: Whisk together the first 7
ingredients until blended. Gradually whisk in
olive oil, blending well. This may be stored in
the refrigerator for up to 2 weeks.
To make the salad: Toss together the first 5
salad ingredients in a large bowl. Drizzle with
cup balsamic vinaigrette, gently tossing to
coat. Serve with remaining vinaigrette.
If you do not like blue cheese, substitute
crumbled goat cheese. Grilled chicken or
shrimp can also be added to make it a com-
plete meal.
Quality Systems Director Julie Finley,
who works in Medlines Mundelein head-
quarters, says the Baby Blue Salad is
appealing to the eyes and the stomach.
She recommends it for dinner parties, lunch-
eons and wedding or baby showers and says
the interesting blend of
flavors always elicits
positive comments.
Still, its so easy to
make that she and her
husband sometimes
make it just for them-
selves during the week.
The Baby Blue Salad is also a healthy food
choice. Pecans may help to reduce blood
cholesterol, Julie tells us, and olive oil con-
tains a potent mix of antioxidants that can
lower your bad (LDL) cholesterol without
affecting your good (HDL) cholesterol.
She points out that Strawberries are in sea-
son right now, which makes this a great time
to try it!
Baby Blue Salad
Nutrition
Information
Servings: 8
Calories: 447
Fat 39. g
Sodium: 251 mg
Fiber: 2.9 g
The Medline employee cookbook is $10. To purchase your own copy, please e-mail Judy at jdesalvo@medline.com.

Forms & Tools
The following pages contain
practical tools for implementing
patient-focused care practices
at your facility.
Sharps Safety
One and Only Campaign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105
Occupational Sharps Injury Log Addendum . . . . . . . . . . . . . . . . . . . .107
Infection Prevention
Spinal Injection Procedures Performed without a Facemask
Pose Risk for Bacterial Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . .108
Hand Hygiene
Your 5 Moments for Hand Hygiene . . . . . . . . . . . . . . . . . . . . . . . . . .110
Patient Safety
10 Patient Safety Tips for Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . .111
Wrong Site Surgery
Main Causes of Wrong Site Surgeries . . . . . . . . . . . . . . . . . . . . . . . .113
Solutions for Reducing the Risk of Wrong Site Surgery . . . . . . . . . . .115
The nal piece
to complete the
latex-free puzzle
in your OR
The protection, performance and comfort of latex without the latex.
Most supplies in the OR are latex-free these days, but for
many operating rooms, surgical gloves remain the last
piece of the latex-free puzzle. Transitioning to latex-free
surgical gloves has been challenging because historically,
the latex-free gloves available have offered inferior t and
feel compared to natural rubber latex.
Medline's SensiCare latex-free surgical gloves are different
because they are made from Isolex, our self-manufactured
synthetic polyisoprene. SensiCare is actually softer and
more elastic than latex. Choose the SensiCare glove
option that best ts your needs.
SensiCare
with Aloe standard thickness,

smooth grip
SensiCare
LT with Aloe standard thickness,

textured grip
SensiCare
Green with Aloe Dark green color,

10% thinner for enhanced tactile sensitivity
SensiCare
Ortho 40% thicker for

extra protection
SensiCare
SLT 5% thinner, textured grip

SensiCare
Surgical Gloves
Launch the QR app
http://www.medline.com/gloves/surgical/latex-
free-surgical-gloves.asp
LEARN MORE ABOUT SENSICARE
SURGICAL GLOVES
1
2
3
For more information, please visit:
www.ONEandONLYcampaign.org
The One & Only Campaign is a public health
campaign aimed at raising awareness among
the general public and healthcare providers
about safe injection practices.
1 needle
1 syringe
1 time
+
infections
0
Its elem
entary!
Patients and healthcare providers must
both insist on nothing less than One Needle,
One Syringe, Only One Time for each and
every injection.
One and Only Campaign Forms & Tools
The DASH
TM
absorbent retractor
bends into just the shape you need
The DASH retractor is 12 times more absorbent than a
standard lap sponge. Its smooth stainless steel core gives
the DASH device strength and malleability. Shape it into
almost any form to gently retract tissues from the surgical
fieldwithout the pinch-point trauma traditional retractors
can cause.
Once you see the DASH in action youll never want to go
back to old, bulky metal retractors.
www.medline.com
THE NEW SHAPE OF SURGERY
DASH
in use gently
retracting the small
intestine while
absorbing uid
Launch the QR app
http://www.medline.com/offers/dash/
1
2
3
TO FIND OUT HOW TO GET YOUR
FREE DASH RETRACTOR SAMPLE
OR17_mag_8.17.11.2_Layout 1 8/18/11 3:08 PM Page 106
Occupational Sharps Injury Log Addendum Forms & Tools
Attachment C Sharps Log Addendum
SAMPLE
Occupational Sharps Injury Log Addendum
(A Supplement to OSHA 300 and 301 Forms)

Insert your organizations confidentiality statement, instructions for completing log and obtaining medical care here.

Name of Employee___________________________________________ Employee ID Number______________________________

Assigned Injury ID #__________________________________________ Employee Work Unit______________________________

Date of Injury_____________________ Time of Injury______________ Completed by________________________Date________
(Employee health/ER staff)
Location of Injury
(Check all that apply)
Finger
Hand L R
Arm L R
Face or Head
Torso
Leg L R
Other: ______________________
___________________________

Sharp Involved
(If known)

Type: _____________________________
Brand: _____________________________
Model: _____________________________

Body Fluid Involved:
____________________________________
____________________________________
____________________________________
Did the sharp being used have engineered
injury protection(s)?
Yes No Dont Know

Was the protective mechanism activated?
Yes No Dont Know

When did the injury occur?
Before activation Dont Know
During activation
After activation

Job Classification

Doctor
Nurse
Intern/Resident
Patient Care Support Staff
Technologist: OR RT
RAD
Phlebotomist/Lab Tech
Housekeeper/Laundry Worker
Trainee, specify:____________
____________________________
Other:_____________________

Location and Department

Patient Room
ICU
Outside Patient Room
Emergency Department
Operating Room/PACU
Clinical Laboratory
Outpatient Clinic/Office
Utility Area
Other:_____________________________
________________________________________
________________________________________

Procedure

Draw venous blood
Draw arterial blood
Injection
Start IV/Central line
Heparin/Saline flush
Obtain body fluid/tissue sample
Cutting
Suturing
Other: ________________________________
____________________________________
________________________________________

Describe, in detail, how the exposure incident occurred (e.g., the procedure being performed, the device being used, the
body part affected, objects or substances involved and how they were involved):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

Note: Developed by the American Hospital Association. This is not an official OSHA form but is based on sharps injury
documentation requirements found in OSHAs revised Bloodborne Pathogens Standard. These new requirements are in
addition to OSHAs employee injury and incident reporting requirements (OSHA 300 and 301 forms).

CDC CLINICAL REMINDER
Spinal Injection Procedures Performed
without a Facemask Pose Risk for
Bacterial Meningitis
Summary:
The Centers for Disease Control and Prevention (CDC) is concerned
about the occurrence of bacterial meningitis among patients
undergoing spinal injection procedures that require injection of
material or insertion of a catheter into epidural or subdural spaces
(e.g., myelogram, administration of spinal or epidural anesthesia, or
intrathecal chemotherapy). Outbreaks of bacterial meningitis
following these spinal injection procedures continue to be
identified among patients whose procedures were performed by a
healthcare provider who did not wear a facemask (e.g., may be
labeled as surgical, medical procedure, or isolation mask),
1
with the
most recent occurrence in October 2010 (CDC unpublished data).
This notice serves as a reminder that facemasks should always be
worn by healthcare providers when performing these spinal
injection procedures.
2
Background:
CDC has investigated multiple outbreaks of bacterial meningitis
among patients undergoing spinal injection procedures. Recent
outbreaks have occurred among patients in acute care hospitals
who received spinal anesthesia or epidural anesthesia, and also
among patients at an outpatient imaging facility who underwent
myelography.
In each of these outbreak investigations, nearly all spinal injection
procedures that resulted in infection were performed by a common
healthcare provider who did not wear a facemask. The strain of
bacteria isolated from the cerebrospinal fluid of these patients was
identical to the strain recovered from the oral flora of the healthcare
provider who performed the spinal injection procedure. These
findings illustrate the risk of bacterial meningitis associated with
droplet transmission of the oral flora from healthcare providers to
patients during spinal injection procedures.
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion

LI C DC C

MI E AL R C I N LI

R DE N MI

Forms & Tools CDC Clinical Reminder

Since facemasks have been shown to limit spread of droplets arising from the oral flora,
3
the CDC has
recommended their use by healthcare providers when performing spinal injection procedures.
2

In addition to wearing a facemask, healthcare providers should ensure adherence to all CDC
recommended safe injection practices including using a single-dose vial of medication for only one
patient.
2

Recommendations:
Anyone performing a spinal injection procedure should review the following CDC recommendations to
ensure that they are not placing their patients at risk for infections such as bacterial meningitis.
x Facemasks should always be used when injecting material or inserting a catheter into the epidural
or subdural space.
2

x Aseptic technique and other safe injection practices (e.g., using a single-dose vial of medication or
contrast solution for only one patient) should always be followed for all spinal injection
procedures.
2

These recommendations apply not only in acute care settings such as hospitals, but in any setting where
spinal injection procedures are performed, such as outpatient imaging facilities, ambulatory surgery
centers, and pain management clinics.
Additional information is available at:
http://www.cdc.gov/hicpac/2007IP/2007ip_part3.html
References:
1. Centers for Disease Control and Prevention. Bacterial meningitis after intrapartum spinal
anesthesia - New York and Ohio, 2008-2009. MMWR Morb Mortal Wkly Rep. 2010;59(3):65-9.
2. Centers for Disease Control and Prevention. 2007 Guideline for isolation precautions: preventing
transmission of infectious agents in healthcare settings. Available at:
http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf. Accessed January 25, 2011.
3. Philips BJ, Fergusson S, Armstrong P, Anderson FM, Wildsmith JA. Surgical face masks are effective
in reducing bacterial contamination caused by dispersal from the upper airway. Br J Anaesth.
1992;69(4):407-8.
NCEZID Atlanta:
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-63548
Email: cdcinfo@cdc.gov Web: www.cdc.gov

CDC Clinical Reminder Forms & Tools
Your 5 Moments

for Hand Hygiene

1
2
3
4
5
WHEN? Clean your hands before touching a patient when approaching him/her.
WHY? To protect the patient against harmful germs carried on your hands.
WHEN? Clean your hands immediately before performing a clean/aseptic procedure.
WHY? To protect the patient against harmful germs, including the patient's own, from entering his/her body.
WHEN? Clean your hands immediately after an exposure risk to body fluids (and after glove removal).
WHY? To protect yourself and the health-care environment from harmful patient germs.
WHEN? Clean your hands after touching a patient and her/his immediate surroundings, when leaving the patients side.
WHEN? Clean your hands after touching any object or furniture in the patients immediate surroundings,
when leaving even if the patient has not been touched.
BEFORE TOUCHING
A PATIENT
BEFORE CLEAN/
ASEPTIC PROCEDURE
AFTER BODY FLUID
EXPOSURE RISK
AFTER TOUCHING
A PATIENT
AFTER
TOUCHING PATIENT
SURROUNDINGS
1
2
3
BEFORE
TOUCHING
A PATIENT
4
AFTER
TOUCHING
A PATIENT
5
AFTER
TOUCHING PATIENT
SURROUNDINGS
B
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WHO acknowledges the Hpitaux Universitaires de Genve (HUG), in particular the members of the Infection Control Programme, for
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m u c do s i h t n i d e n ai t n o c n o i t a m r o f n i e

their active participation in developing this material. WHO acknowledges the Hpitaux Universitaires de Genve (HUG), in particular the members of the Infection Control Programme, for
n o i t a z i n a g r O h t l a He d l r o W e h t l l a h s t n e
l a i r e t a m d e h s i l b u p e h t , r e v e w o H . t n e m

their active participation in developing this material.
t i m ro f g n i s i r a s e g a m a d r o f e l b a i l e b n
y t an r r a w t u ho t i w d e t u b i r t s i d g n i e b s i

. e s u s t
, d n i k y n a f o
Forms & Tools Hand Hygiene
Patient Safety Tips Forms & Tools
Advancing Excellence in Health Care
www.ahrq.gov
Agency for Healthcare Research and Quality
PATIENT
SAFETY
10 Patient Safety Tips for Hospitals
Medical errors may occur in different health care settings, and those that happen in hospitals can have serious
consequences. The Agency for Healthcare Research and Quality (AHRQ), which has sponsored hundreds of patient
safety research and implementation projects, offers these 10 evidence-based tips to prevent adverse events from
occurring in your hospital. Ordering information and links to free AHRQ tools are also provided.
1. Prevent central line-
associated blood stream
infections. Be vigilant
preventing central line-
associated blood stream
infections by taking five steps
every time a central venous
catheter is inserted: wash
your hands, use full-barrier
precautions, clean the skin
with chlorhexidine, avoid
femoral lines, and remove unnecessary lines. Taking
these steps consistently reduced this type of deadly health
care-associated infection to zero in a study at more than
100 large and small hospitals.
i
Additional AHRQ
resources on preventing health care-associated infections
are available at http://www.ahrq.gov/qual/hais.htm.
2. Re-engineer hospital discharges. Reduce potentially
preventable readmissions by assigning a staff member to
work closely with patients and other staff to reconcile
medications and schedule necessary followup medical
appointments. Create a simple, easy-to-understand
discharge plan for each patient that contains a medication
schedule, a record of all upcoming medical
appointments, and names and phone numbers of whom
to call if a problem arises. AHRQ-funded research shows
that taking these steps can help reduce potentially
preventable readmissions by 30 percent.
ii
An online
toolkit is available at http://www.bu.edu/
fammed/projectred/.
3. Prevent venous
thromboembolism. Eliminate
hospital-acquired venous
thromboembolism (VTE), the
most common cause of
preventable hospital deaths, by
using an evidence-based guide
to create a VTE protocol. This
free guide explains how to take
essential first steps, lay out the
evidence and identify best practices, analyze care
delivery, track performance with metrics, layer
interventions, and continue to improve. Ordering
information for Preventing Hospital-Acquired Venous
Thromboembolism: A Guide for Effective Quality
Improvement (AHRQ Publication No. 08-0075) is
available at http://www.ahrq.gov/qual/vtguide/.
4. Educate patients about
using blood thinners safely.
Patients who have had surgery
often leave the hospital with a
new prescription for a blood
thinner, such as warfarin
(brand name: Coumadin
), to
keep them from developing
dangerous blood clots.
However, if used incorrectly,
blood thinners can cause
uncontrollable bleeding and are among the top causes of
adverse drug events. A free 10-minute patient education
video and companion 24-page booklet, both in English
and Spanish, help patients understand what to expect
when taking these medicines. Ordering information for
Staying Active and Healthy with Blood Thinners (AHRQ
Publication No. 09-0086-DVD) and Blood Thinner Pills:
Your Guide to Using Them Safely (AHRQ Publication
No. 09-0086-C) is available at http://www.ahrq.gov/
consumer/btpills.htm.
5. Limit shift durations for
medical residents and other
hospital staff if possible.
Evidence shows that acute and
chronically fatigued medical
residents are more likely to
make mistakes. Ensure that
residents get ample sleep and
adhere to 80-hour workweek
limits. Residents who work 30-
hour shifts should only treat
patients for up to 16 hours and
should have a 5-hour protected sleep period between 10
p.m. and 8 a.m.
iii
Resident Duty Hours: Enhancing Sleep,
Supervision, and Safety is available at http://
books.nap.edu/openbook.php?record_id=12508&page=R1.
6. Consider working with a Patient
Safety Organization. Report and share
patient safety information with Patient
Safety Organizations (PSOs) to help others
avoid preventable errors. By providing both
privilege and confidentiality, PSOs create a secure
environment where clinicians and health care
organizations can use common formats to collect,
aggregate, and analyze data that can improve quality by
identifying and reducing the risks and hazards associated
with patient care. Information on PSOs and Common
Formats is available at http://www.pso.ahrq.gov/.
7. Use good hospital design
principles. Follow evidence-
based principles for hospital
design to improve patient safety
and quality. Prevent patient falls
by providing well-designed
patient rooms and bathrooms and
creating decentralized nurses stations that allow easy
access to patients. Reduce infections by offering single-
bed rooms, improving air filtration systems, and
providing multiple convenient locations for hand
washing. Prevent medication errors by offering
pharmacists well-lit, quiet, private spaces so they can fill
prescriptions without distractions. Ordering information
for a free 50-minute DVD, Transforming Hospitals:
Designing for Safety and Quality (AHRQ Publication No.
07-0076-DVD), is available at http://www.ahrq.gov/
qual/transform.htm.
8. Measure your hospitals
patient safety culture. Survey
hospital staff to assess your
facilitys patient safety culture.
AHRQs free Hospital Survey on
Patient Safety Culture and
related materials are designed to
provide tools for improving the
patient safety culture, evaluating
the impact of interventions, and
tracking changes over time. If your health system
includes nursing homes or ambulatory care medical
groups, share culture surveys customized for those
settings. Free patient safety culture surveys for hospitals
(AHRQ Publication No. 04-0041), nursing homes
(AHRQ Publication No. 08-0060), and medical offices
(AHRQ Publication No. 08(09)-0059) are available at
http://www.ahrq.gov/qual/patientsafetyculture/.
9. Build better teams and rapid response
systems. Train hospital staff to communicate
effectively as a team. A free, customizable
toolkit called TeamSTEPPS,
which stands for Team Strategies
and Tools to Enhance Performance
and Patient Safety, provides
evidence-based techniques for
promoting effective communication
and other teamwork skills among
staff in various units or as part of
rapid response teams. Materials can be tailored to any
health care setting, from emergency departments to
ambulatory clinics. A free 2
1
2-day train-the-trainer course
is currently being offered in five locations nationwide.
Ordering information for the TeamSTEPPS Multimedia
Resource Kit (AHRQ Publication No. 06-0020-3) and
information on the training sessions are available at
http://teamstepps.ahrq.gov/index.htm.
10. Insert chest tubes safely.
Remember UWET when inserting
chest tubes. The easy-to-remember
mnemonic is based on a universal
protocol from the Joint
Commission and stands for:
Universal Precautions (achieved
by using sterile cap, mask, gown, and gloves); Wider skin
prep; Extensive draping; and Tray positioning. A free 11-
minute DVD provides video excerpts of 50 actual chest
tube insertions to illustrate problems that can occur
during the procedure. Ordering information for Problems
and Prevention: Chest Tube Insertion (AHRQ
Publication No. 06-0069-DVD) is available at
http://www.ahrq.gov/qual/chesttubes.htm.
For free copies of AHRQ tools, please call the AHRQ
Publications Clearinghouse at 1-800-358-9295.
i
Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove
S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel
C. An intervention to decrease catheter-related bloodstream infections
in the ICU. N Engl J Med 2006 Dec 28;355(26):2725-32.
ii
Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM,
Johnson AE, Forsythe SR, ODonnell JK, Paasche-Orlow MK,
Manasseh C, Martin S, Culpepper L. A reengineered hospital
discharge program to decrease rehospitalization: a randomized trial.
Ann Intern Med 2009 Feb 3;150(3):178-87.
iii
Institute of Medicine, 2009. Resident Duty Hours: Enhancing
Sleep, Supervision, and Safety. Washington, DC: The National
Academies Press.
AHRQ Publication No. 10-M008
(Replaces AHRQ Publication No. 08-P003)
December 2009
Forms & Tools Patient Safety Tips
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Joint Commission - Wrong Site Surgery Solutions Forms & Tools
CAUTI
CULPRITS
Nab the Suspects
In Search
of the BEST
Pink Glove
Dancers!
Page 98
Crew Resource
Management
in the OR
The
Aligning practice with policy to improve patient care
FREE CE!
Victoria
Nahum
A Mother Turns
Tragedy into a
Crusade for
Patient Safety
ACOs
A Flexible
Approach
Volume 6, Issue 2
V
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M
E

6
,

I
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S
U
E

2
T
H
E

O
R

C
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C
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N
w
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l
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2011 Medline Industries, Inc. Medline and
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CAUTI

prescription drug packaging

is a registered trademark used for Retail Pharmacy Services and owned

Its the health care equivalent of

OR Patient Warming System

I was quickly shouted out of the

Flexible wound closure thats easy on your budget

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OR17_mag_8.17.11.2_Layout 1 8/18/11 5:06 AM Page 61

OR17_mag_8.17.11.2_Layout 1 8/18/11 5:06 AM Page 68

sensation Pink Glove

OR17_mag_8.17.11.2_Layout 1 8/18/11 5:09 AM Page 102

with Aloe standard thickness,

LT with Aloe standard thickness,

Green with Aloe Dark green color,

Ortho 40% thicker for

SLT 5% thinner, textured grip

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