Surgical procedures
Health-care workers should be trained to reduce misinformation or inconsistent information that can lead to errors, such as wrong-site surgery [19–21].
Scheduling the procedure
Office schedulers must carefully verify patient documentation before scheduling the procedure. All surgery requests must be in writing. No verbal requests by the medical staff should be accepted. An appropriate scheduling form reduces misunderstandings. Illegible handwriting, unapproved abbreviations, and cross-outs can be pitfalls if not clearly understood by office schedulers. Electronic medical records can improve the safety process, reducing misunderstandings and missing documents [21–23].
Verification of every pertinent document such as consent, history, physicals, and surgeon orders at time of scheduling is mandatory. If any inconsistency is found within the documentation during the process, office-schedulers should be instructed not to proceed to the next step without solving conflict or absence of information.
Pre-operative
The preoperative visit is another opportunity to identify and correct any inconsistencies or lack of information in the documentation regarding the surgical procedure. All documents should be checked during the visit and the patient should confirm identity, site of surgery, allergies, and other pertinent information if possible. All discrepancies must be corrected on all forms and documents prior to moving forward.
The informed consent must be received prior to the procedure and the patient must fully understand their procedure including things such as complications, additional procedures, placement of stents, and important alternative treatments that may be used in the present case [19, 20, 24, 25].
Marking the site of the procedure is critical in order to avoid wrong-site surgery. Preferentially, site marking should be performed with the patient’s involvement [26, 27]. The site must be marked by a licensed practitioner who is responsible for the procedure and will be present when the procedure is performed. The marks should be unambiguous and uniform within the institution and should be semi-permanent to be visible after skin preparation and draping [28].
In case marking the site is not possible due to technical or anatomical impediments (mucosal surfaces, minimal access procedures, endoscopic procedures, natural orifice procedures, etc.), the institution should have a written process to ensure that the correct site is operated on [29, 30]. Alternatively, radiopaque markers can be used in the procedures involving fluoroscopy [29, 31, 32].
Another important aspect of patient safety is the surgical material used during the procedure. Availability of all instruments and special materials (e.g., guide wires, laser fibers, scopes, stents, loops, prosthesis, etc.) should be verified prior to surgery and checked to ensure that they are the appropriate size for the patient [33].
Before starting the procedure
Full implementation of safety checklists in surgery has been linked to improved outcomes [9, 13, 34, 35]. The World Health Organization checklist is designed to identify a potential error before it results in harm to a patient. This checklist should be followed in the appropriate manner.
In a study by Russ S. et al., more than 40 % of cases had absent team members, and over 70 % of team members failed to pause and focus on the checks [13]. Performing a time-out and implementing a check list in the operating room does not mean that the patient is safe. Team members still have to adhere to the protocols and follow them with full attention. Surgical safety performance was better when surgeons led the procedure and all team members were present and paused [13]. The time-out must be documented at its completion. When multiple procedures are going to be performed on the same patient by different providers, the check list and time out should be performed for each procedure.
In the era of digital images, displaying the CT-scan, X-ray, and all other pertinent images during the procedure on an auxiliary monitor can improve patient safety [36, 37].
The consequences of positioning related injuries are preventable but can be profound and can result in morbidity and litigation [38]. Neurological, vascular, musculoskeletal, and pressure ulcers are the most common position related injuries in surgical patients [38, 39]. Neurological complications can be avoided by placing forearms in neutral position or slightly supinated to minimize pressure in the cubital tunnel [40]. Straps should be properly placed to maintain the correct limb position during the procedure even if the surgical table is moved. The patient’s head should be placed in a neutral position and the arm should not exceed abduction of more than 90° to prevent brachial plexus injury. Straps should not be too tight to avoid ischemia and compartmental syndrome. Padding under osseous prominences can help avoid pressure-related complications. Urologists must be careful to avoid possible compartment syndrome (limbs) when positioning patients for open, endoscopic, and laparoscopic surgeries [41–43].
Before discharge from the facility
Discharge planning has been shown to impact patient safety, patient outcomes, and can prevent readmissions and improve patient satisfaction [44–46]. Patient education is crucial when they are discharged home with catheters, stomas, stents, drains, or any other medical device that needs special care. Patient education can reduce complications and improve patient quality of life after surgical procedures [47–49]. Heath care workers must be aware that language barriers, socioeconomic status, and age can impact patient comprehension of instructions [49–51]. Written instruction must also be provided and follow-up visits should be scheduled prior to patient discharge from the facility.
Laboratory exams, biopsies, and surgical pathology
Office-procedures such as biopsies (prostate, skin lesion, bladder), urine cultures, and blood samples are routine in a urology clinic. The large amount of patients, multiple samples from the same patient, lack of staff, and lack of continuous education and training of health care workers may increase medical errors. Approximately 1 % of general laboratory specimens are misidentified and can lead to serious harm for patients [52].
For patient safety, prevention is the goal and can be accomplished by implementing safety strategies. Health care workers responsible for specific tasks must be educated and motivated to perform those tasks with as few errors as possible [53]. Written policies and protocols detailing responsibilities must be implemented along with a strategic plan to detect errors when these responsibilities are not met. Successful completion of required tasks must be documented in order to move forward, especially in those tasks that are performed as a prerequisite to others [53].
To make the process as simple as possible, reduce the number of steps between collecting the samples and receiving the laboratory report. Redundancy checks must be encouraged in certain steps of the process in order to increase the chance of detecting mistakes before a therapeutic decision is made, especially when the decision is irrevocable and the potential damage caused by error cannot be undone.
Procedures that involve biopsy and tissue sampling a specimen may pass through the hands of more than twenty individuals in several workplaces until the final pathology report is given [54]. These handoffs significantly increase the risk of a mix-up and can lead to serious diagnostic errors. Mutual cooperation for supervision of clinicians, technicians, and administrative assistants is essential to prevent and detect errors. The most vulnerable steps of the biopsy process include labeling of the specimens, appropriate request forms, and accessioning of biopsy specimens [54].
The use of information technology for data entry, automated systems for patient identification and specimen labeling, as well as two or more identifiers during sample collection are important steps to reduce misidentification [54, 55] (Fig. 3). If misidentification is detected, rejection then recollection is the most suitable approach to manage the specimen. DNA analysis to assist with correct identification can be used when recollection is not available [56].
Medication safety
Medication safety can be improved by utilizing the five R’s: right drug, right route, right time, right dose, and right patient. Medication errors are barriers that prevent the right patient from receiving the right drug in the right dose at the right time through the right route of administration at any stage during medication use, with or without the occurrence of adverse drug events [57]. Medication errors represent the largest single cause of errors in the hospital setting in the United States, and are estimated to harm at least 1.5 million patients annually [57, 58].
In 2009, the government spent $30 billion in taxpayer subsidies toward the transition to digital medical records. Electronic medical records helped to decrease medication error and medication reconciliation by up to 50 % [59, 60]. Systems that use information technology, such as computerized physician order entry, automated dispensing, barcode medication administration, electronic medication reconciliation, and personal health records are vital in the prevention of medication errors [58]. Electronic medical records provide pharmacists with the ability to rapidly screen the medication regimens of hospitalized patients and deliver timely, point-of-care intervention when indicated [61].
The most common prescribing errors are incorrect drug, incorrect dose, allergies, and drug-drug interaction. Physicians have to keep the most common mistakes in mind and frequently check for errors.
Prior to prescribing any medication, the health-care professional must choose the appropriate medication for a given situation, considering factors such as allergies, route, dose, time, and regimen. Each patient may need a different treatment plan. It is important to tailor prescriptions for individual patients, identifying allergies, pregnancy, lactation, age, co-morbidities, breastfeeding, size, and patient weight. Health-care workers must be familiar with the medications they prescribe and need to know the medications in their specialty that are associated with high risk of adverse events. Remember the five R’s when prescribing and administering medication. Health-care professionals must monitor whether prescribed medication is clinically successful, does not cause harm, and is corrected when necessary.
Drug interactions can lead to serious adverse events or decrease drug efficacy [62]. Prescribing health-care workers should ask patients of any use of over-the-counter medications or dietary supplements because they are frequently under reported and may cause drug interactions [9]. Prescribing the generic name of drugs simplifies the communication among health-care workers, reducing errors. However, patients need to be educated that their medication may be called by different names (brand and generic name) and they should be encouraged to keep a list of their medications, including both the brand and generic name of each drug.
Education and training medical students and surgical specialty residents
Technological advances, novel surgical devices, and minimally invasive techniques are rapidly increasing within the surgical community. Concerns about device safety and training are increasing, protecting patients from harm. Devices need to be extensively evaluated in research before and after FDA approval [63–67].
In teaching institutions, the participation of residents and fellows during the surgical procedure is integral to instill patient safety fundamentals in the trainees. Although involving trainees increases the duration of the procedure and increases length of stay for the patient, there are no significant differences in outcomes when trainees are involved. Residents and fellows provide extra assistance while also strengthening their skills to become knowledgeable and confident doctors [68–71].
Finally, due to new mandatory work hours residents are subjected to follow a pre-planned schedule during their duty hours and it is imperative to consider ensuring that patient safety is not compromised by breaks in the continuity of care. The handover process is a necessary bridge to continuity and safer patient care. Medical educators and clinicians should work toward adopting and testing principles of optimal handovers processes in their local practices applying the knowledge of patient safety issues discussed in this report [72].