Patient Safety Tips

The following patient safety tips were submitted as part of the first-ever AAOS Patient Safety Tip Contest. Thanks to all who entered for your ongoing efforts to promote patient safety.

Surgical Safety

At our hospital, prior to surgical incision we require a "pause for safety." This requires that the attending physician be present in the room. The anesthesia staff, nursing, and surgical team review the chart and ID bracelet of the patient to confirm the patient's identity. Once this is confirmed, the surgical consent is read out loud and appropriate signatures on the consent are verified.
Submitted by Joseph Abboud, MD, Broomall, Penn.

Whenever a sponge or lap is placed inside the patient, the technician places a mosquito clamp on the gown of the junior resident (the person who will be closing). When the sponge is removed, it is removed with this clamp. This is another check-and-balance on the sponge count. If there is still a clamp on the resident at the time of closure, we missed a sponge. It is simple, costs nothing, and helps prevent errors. Remember you only leave a sponge in a patient when the sponge count is incorrect.
Submitted by Glenn Rechtine, MD, Gainesville, Fla.

When reading X-rays, check the label on EACH film to be certain it is the correct patient and that the date of the X-ray is the one you were expecting (especially when reviewing a series of X-rays).
Submitted by Kenneth Singer, MD, Eugene, Ore.

Physicians operating with the electrocautery should use a short piece of rubber tubing (such as from an appropriately sized drain tube) to ensheath all but the most distal tip of the cautery to avoid any inadvertant cauterization away from the tip (such as on the skin or other sensitive nearby structure).
Submitted by Jason Hoyt Thompson, MD, Seattle, Wash.

Do not proceed with a procedure unless you have a copy of the patient's medical records and corresponding imaging studies in the operating room.
Submitted by Mark D. Brown, MD Maimi, Fla.

As part of the "time-out" procedure, the usual patient identification, surgical procedure, and correct surgical site are accomplished by the entire operating room team before positioning, prep, and incision. Here's an additional tip for total joint procedures (and perhaps other cases): The surgeon also checks to see the patients X-rays are hanging in the room; checks to be sure all potentially needed instruments, implants, and bone grafts are open or immediately available for the case; then the surgeon calls "time-in." Nothing proceeds further until "time-in" follows the "time-out."
Submitted by David E. Attarian, MD, Durham, N.C.

When removing Coban or similar wrap after extremity surgery, first try to unwrap the wrap rather than cutting it off. I have seen three injuries from removing wraps after surgery: one removal of the tip of an ear during cervical spine surgery, one skin avulsion over the anterior tibia from pressure from the scissors, and one forearm laceration in an elderly patient whose loose skin had folded up inside the stockinette. I have studied this by timing how long it takes to unwrap it versus how long it takes to cut it off with scissors. The scissors are more dangerous and are not faster.
Submitted by Adam S. Bright, MD, Sarasota, Fla.

For hospital/clinic settings, having pre-printed standard order sets, discharge care for specific procedures, and contact phone numbers for the physicians. As long as they are flexible enough to allow small changes/additions, these will save time, lessen the chance of forgetting orders/care instructions, reduce errors in legibility, and give written instructions for patients in case they forget verbal instructions. They will also give contact numbers that are up-to-date and lessen anxiety when trouble occurs.
Submitted by Frederic Chi, MD, Rochester, N.Y.

Use continuous pulse oximetry for 48 hours postoperative for patients receiving parenteral or intrathecal narcotics. For the past two years, I have been placing all postoperative inpatients receiving intrathecal or parenteral narcotics on continuous pulse oximetry for 48 hours postoperatively. No patient on this program has required narcotic reversal nor have any been found oversedated/hypoxic during the graveyard shift. The only drawback is some patients with chronically low oxygen saturation levels get interrupted sleep from the alarm. I believe this has been particularly useful with the hospital transition away from registered nursing staff to certified nursing assistants as well as with understaffing of the inpatient units. In addition, on postoperative checks, I have immediate real time information on the patient's pulse and pulmonary status.
Submitted by. Jeffrey P. Menzner, MD, Boise, Idaho

When confirming the correct site prior to surgery, do not say, "Is that right?" Instead, say: "Is that correct?" to avoid patient confusion between right and left limb.
Submitted by Arvind D. Nana, MD, Fort Worth, Texas

Use a simple index card to promote safety; it's a very simple approach to avoid major complex problems My practice is all knee problems and knee arthroscopy but this would work for any aspect of orthopaedic surgery. One or two days before surgery, I personally make a list of all surgeries on a 3x5 index card. I personally review the patient's chart and confirm in at least two or three places (such as the patient intake sheet, imaging studies, my handwritten and typed notes) the correct side (R or L). I check for specific diagnosis, allergies, and other medical issues. The index card entry reflects all of the above information as well as additional things such as any special equipment that might be needed, and any personal patient-related tidbits. Card would have list something like this, with one simple line per patient:

1. Jones, John - R MM, ?defect (?MF) ALLERGY PCN (translation: right knee, possible chondral defect needing microfracture, patient allergic to penicillin)

2. Smith, Sue- L LM, mild DJD, ?LB, NIDDM (translation: left knee, lateral meniscus tear and mild arthritis, question of loose body, diabetes issues to consider) On the day of surgery, I review the card on the way to the hospital. Before each surgery, in the holding area with the patient, I check the card a final time.
   Submitted by Nicholas A. DiNubile, MD, Havertown, Penn.

Just prior to making a surgical incision, the actual surgical booking sheet that was filled out in the office and is now part of the operating room record is reviewed by the surgeon to re-confirm patient name, operative procedure, and side.
Submitted by Murray J. Goodman, MD, Salem, Mass.

I feel the number one thing an orthopaedic surgeon can do to improve patient outcomes is to make sure there is a competent anesthesia provider- CRNA or MDA-familiar with the procedure about to be performed. The second thing to do is have a conversation with the anesthesia provider about the surgery, anesthetic, patient-controlled anelgesia and pain management. It is common practice for surgeons to be completely unaware of the anesthetic course chosen for their patients. Cooperation and communication between the surgeon and the anesthesia provider can only improve overall patient management and outcomes.
Submitted by Dennis O'Leary, CRNA, Northridge, Calif.

Do not mark the correct site with an X. This may be confused with the incorrect site. Use a name or initials written by the patient to designate the appropriate limb.
Submitted by Arvind D. Nana, MD, Fort Worth, Texas

Correct site must be confirmed by the patient, operating surgeon, consent, and x-rays prior to proceeding to the operating room.
Submitted by Arvind D. Nana, MD, Fort Worth, Texas

Avoid playing "telephone" with descriptions for surgical procedures. Avoid abbreviations when the surgeon lists the case and throughout to the end of the procedure. When an office books surgical cases and when the facility generates an operating room list or schedule, it is important that the surgeon's language is consistent throughout in describing and naming the procedure. For example a case such as a "tenolyis right ring finger flexor digitorum profundus" should not become "tenolysis tendon right ring finger" on the consent and "release tendon right ring" on the operating room schedule. Another cause for this is computer software "standardizing" the description. If an operating room schedule or the hospital's admitting booking is CPT-code driven and does not use the surgeon's language, this problem may be seen quite often. Having the same language in the orthopaedic surgeon's notes, in the consent form, in the surgical schedule and in any other documentation avoids possible problems, such as doing the wrong procedure, operating on the wrong site or leaving a portion of the procedure out when multiple items are listed and "condensed" in the name of space or software.
Submitted by Jeffrey Wint, MD, Springfield, Mass.

Take the patient's chart with all X-rays to the operating room and review it before the case, even if you do it the day before and carry out the correct side surgery routine. Ensure that the chart has a up-to-date medication list with all possible crossreactions checked by quality software. Insist that your patients carry the same list.
Submitted by William A. Dolan, MD, Rochester, N.Y.

When I interview a patient preoperatively, I stand on the same side of the patient as the side I will be standing on during surgery. For example, I stand on the patient's right side during the interview if I plan to do a right shoulder or a right knee surgery.
Submitted by James C. Esch, MD, Oceanside, Calif.

To prevent premature and unintentional removal of drains from a surgical wound, secure the drain tubing to its entry site at the skin by applying two full-length adhesive steri-strips. These adhesive strips can be applied si that half of each strip wraps around the drain tubing in an antegrade spiral fashion, with the remaining half applied directly to the skin and in line with the drain tubing. Based upon anectdotal experience at our institution, this technique has proven to be a simple, yet remarkably reliable, way of preventing accidental surgical drain removal. This technique has direct implications for patient safety-particularly in the fields of total joint arthroplasty, postoperative drainage of infection, and musculoskeletal tumor surgery where hemostasis is a critical factor in reducing risk of local tumor spread and potential metastases.
Submitted by Vincent Paul Novak, MD, Winston-Salem, N.C.

During operations on the foot, ankle or lower leg, but especially the forefoot, cautery burns to the posterior aspect of the calf can occur if the cautery is laid down and slips between the legs and behind the operative leg. Although the audio output of the cautery machine should alert the surgeon that the weight of the leg is activating the cautery and possibly causing a burn, by then it may be too late. There are two safety measures to prevent this. The first is to use a pocket for the cautery and get in the habit of always putting it back. I usually attach the pocket to the drapes just above the opening for the leg in the extremity drape. The second is to operate with a roll of towels under the ankle/achilles area to elevate the calf off the surface of the draped operating room table. I usually make a tight roll of towels about 3" to 4" in diameter and hold it with a small towel clip. An elevated leg is unlikely to discharge the cautery.
Submitted by Ian Alexander, MD, Akron, Ohio

In the preoperative area, paint the operative site with betadine (if there is no iodine allergy). This not only prepares the skin, it also identifies the proper surgical site. Then cover it with a warm towel. Patients respond well to this treatment. Betaidine is an excellent and aseptic marker.
Submitted by Alan Wolf, MD, Ketchikan, Alaska

Implement "Time Out" in the room with the scrub, surgeon and anesthesiologist in attendance, just before the patient is passed from the scrub to the surgeon. Either the anesthesiologist or the circulator in the room reads aloud the surgical consent. Surgery proceeds when all agree with each other and the consent.
Submitted by Donna Nowak, Stony Brook, N.Y.

For the "Sign Your Site" initiative, it is not enough to place yes and your initiails on the operative site. That marking can be covered and during prepping and draping; it can be thought to have washed off and the correctly marked limb covered. We have been marking the incorrect side with "no," in addition to marking the correct side with initials and "yes." We had an near-miss incident of wrong-side surgery with just the "yes" and the initials method. Now we always mark the wrong side with "no" in addition the right side with "yes." There have been no further incidents.
Submitted by Richard Iorio, MD, Burlington, Mass.

The surgeon should call the primary care referring physician yourself before recommending elective surgery to maximize good outcomes. I am a spine surgeon, and I find it very useful to know that a patient is seeing multiple doctors. The call can tell you about medications, drug abuse problems (in which case a pain clinic is a better option), or a real chronic pain condition (which is much easier to address if discussed before the surgery).
Submitted by Wojciech Bulczynski, MD, Malden, Mass.

Patient Education

Patient information literature concerning the overall surgery experience as well as the specific procedure is very helpful. So much of surgical success relies on the patient's knowledge and expectations of the entire process. Thus, things like maps and directions, information written down to remind them later, and phone numbers or people to call if they have problems or questions can be very useful. Further, it's much better to inform patients of their pain management protocols, or the fact that they won't be able to drive for 6 weeks, or planned postoperative rehabilitation before surgery rather than afterward. They react so much better if they are aware of things and are able to make plans if necessary. Such materials also warn them of the signs of infection, care of their cast, how to do their exercises (complete with pictures), and the "no-no's" after surgery, all of which help to improve outcome and diminish problems.
Submitted by Kevin L. Smith, MD, Seattle, Wash.

When preparing patients for elective orthopaedic surgery, make sure they lose weight, stop smoking, discontinue unnecessary medications, herbal supplements, aspirin and obtain medical clearance for the procedure.
Submitted by Mark D. Brown, MD, Maimi, Fla.

Ask women of childbearing age about the use of birth control pills. Patients often do not consider this as a medication, and thus do not mention this in the history when asked about medications. As such, they may be at risk for deep venous thrombosis.
Submitted by Arvind D. Nana, MD, Fort Worth, Texas

Provide a small drug handbook to all new patients, as a part of their admission packets. This way, patients can educate themselves on the medications they are currently on and/or will receive while an inpatient. This could also be done at the physician's office. A well-informed patient, especially in medication awareness, could improve outcomes through compliance with prescribed drugs and a better use of narcotics. Education is mainly done at the pharmacy, when a prescription is picked up. Providing this education from the beginning, when the script is written, and reinforcing it at the pharmacy, will result in more patient knowledge regarding the medications. Hospital information is key to safety-there are so many more drugs dispensed in a hospital setting, and many are unfamiliar to the patients.
Submitted by Barbara Taller, RN, Naperville, Ill.

Have the orthopaedic surgeon's staff give the patient a hand-out of what the patient should do on a month-to-month basis for about six months. The hand-out should cover exercise, movrments, bathing, etc. Also make sure all medical personal wash hands before they ever touch a patient Instruct patients on a nutritious diet of vegetables, whole grains, omega-3 fats, nuts, etc.
Submitted by Rocky Rocco, Pearland, Texas

Hand out preprinted postoperative instructions with exercise directions before the operation. Make sure hospital and ambulatory surgery facilities also have and use them.
Submitted by William A. Dolan, MD, Rochester, N.Y.

Explain to patients the necessity of stopping over-the-counter/prescription anti-inflammatories if they develop nausea,vomiting or diarrhea. Acute renal failure can occur if this is not done. Patients in the hospital with severe nauasea and vomiting should also stop any anti-inflammatory medication.
Submitted by David Allmacher, MD, Missoula, Mont.

My typed discharge instructions for patients who have had surgery include instructions for the patient to move the ankles up and down 20 times each hour.

Explanation: Deep venous thrombosis (DVT) is a known risk of surgery, one that is reviewed with the patient before the surgery as part of the informed consent. To create an environment less conducive to the formation of a DVT, all patients-whether or not there is a known risk factor for DVT-receive the instruction noted above. Although my operations are more often outpatient shoulder surgeries, this instruction should be used for all orthopaedic procedures.

Addendum: As an aside, this instruction should be included with the orders for hospital admissions and discharges, both operative and nonoperative. For completeness, this instruction assumes the presence of one or both ankles and is not used when this is not the case.
Submitted by Jonathan B. Ticker, MD, Massapequa, N.Y.

Office/Hospital Visits

The office visit can be stressful and overwhelming, for the layperson, for anyone. Things like diagnosis, treatment options, risks and benefits, planned course of action, etc. can all be lost on the patient in that one short visit. So, sending a copy of notes that reiterate all of the above can be a superb reminder of things ("there is a chance of infection, etc." or "no active use" or "this can take several months") as well as a check-and-balance to make sure that the information gathered is complete and correct ("no, it was my left arm, not my right" or "I'm also allergic to penicillin"). Such notes can also help apprise other providers of the situation, plans, goals, etc. This keeps them informed, minimizes potential for duplication of medications, lets them know if/how they can help, and avoids inappropriate recommendations to the patient.
Submitted by Kevin L. Smith, MD, Seattle, Wash.

Give the patient a copy of their pertinent medical records and imaging studies to bring with them to the hospital for their procedure.
Submitted by Mark D. Brown, MD, Maimi, Fla.

On preoperative visit, tell patient to not let anesthesia be given unless I or my assistant has signed site.
Submitted by Fred Nelson, MD, Detroit, Mich.

Physicians: At each visit with a patient-office, hospital rounds, ER, etc.-call the patient by his/her name to be certain that person is the correct person.
Submitted by Kenneth Singer, MD, Eugene, Ore.

Every dictation in the chart should begin with the body part and the side. "Mr. Jones was seen today in follow-up for his left elbow."
Submitted by Kenneth Singer, MD, Eugene, Ore.

If you must leave the room while administering a Cortisone shot, please remember to confirm location/side of shot when you return to room to prevent wrong-site injection.
Submitted by Adam S. Bright, MD, Sarasota, Fla.

Never assume a test result is OK because you weren't called; pursue the result proactively.
Submitted by Mark A. Sobel, MD, Marlton, N.J.

Put up the bed rail after examining the patient in the hospital. This prevents accidental falls.
Submitted by Arvind D. Nana, MD, Fort Worth, Texas

Don't forget the bladder. Even though it is not really an orthopedic problem, we come across it all the time. A patient admitted with a fractured hip or low back pain may not be able to void due to pain. If the bladder distends to more than 1000 cc, the patient may be permanently incontinent. Don't assume the admitting physician will ask.
Submitted by Wojciech Bulczynski, MD, Malden, Mass.

Require nurses to do rounds with the physicians and promote better communication between health care professionals.
Submitted by Walter Poprycz, MD, Haddon Heights, N.J.

Use preoperative antibiotics for all cases deeper than dermis; irrigate wounds copiously. Keep siderails on bed up. Obtain consent forms. Remember that eye contact for two minutes is worth ten minutes of conversation.
Submitted by John Bouillon, MD, Dubai, United Arab Emerits

Always try to dictate the patient's medical record of an office visit in the presence of the patient in the exam room. This does three things:

1. It reiterates what you have told the patient as far as diagnosis and plan and allows the patient to correct any history in which you may have erred.

2. You conform with privacy/HIPAA regulations.

3. You stay current in your medical records and don't have to rely on memory.

Submitted by C. Thomas Hopkins, MD, Griffin, Ga.

To increase awareness of patient safety in our hospital's "Patient Safety Is No Accident" awareness campaign, we conducted a "Patient Safety" poster contest for all the individual departments in the hospital (such as medical records, nursing service, housecleaning, security, administration, etc.). As Chief of Staff, I was one of the judges who selected the three best posters. Each of the top three poster-winning departments received an award-a hosted meal at a local restaurant or take-out pizza. The contest helped all to focus in on patient safety issues as it applies to their own departments and increased awareness. Though some of the departments were reluctant to participate at first, all eventually had a good time coming up with useful (and sometimes humorous) ideas.
Submitted by A. Herbert Alexander, MD, Ketchum, Idaho

Conducting a medication interview with the patient prior to surgery can minimize problems in the hospital. Asking about past problems or successes with pain medication, clarifying home medication names and dosages and making sure these are continued in the hospital can reduce problems that might prolong hospital stays.
Submitted by Douglas Wooley, MD, Missoula, Mont.

1. Post a sign above the entry to every patient room in every hospital that says: STOP! Wash hands BEFORE entering.

2. Post a sign at every entrance to every hospital that says: Prevent Infections, the Number One Killer in the World. Please do not shake hands with anyone in our hospital.

Patient safety is priority number one. Nosocomial infections and infections with resistant organisms are major problems in most hospitals. Failure to wash hands for 20 seconds with good friction, or to wash hands with an alcohol antiseptic, promotes the spread of organisms that cause infections. The western tradition of shaking hands is an unsanitary custom that should be gradually changed. Doctors and hospitals can take the lead in this effort for the good of our patients and society as a whole.
Submitted by Richard F. Santore, MD, San Diego, Calif.

In every routine low back pain admission, ask these three key questions:

1. Is the patient incontinent?

2. Is there a fever?

3. Is there any weakness?

The first two are most serious and most often forgotten in everyday practice.
Submitted by Wojciech Bulczynski, MD, Malden, Mass.

Patient Activities

Watch your health care professional. If you do not observe him washing his hands before he examines you, request him to please do so.
Submitted by Lucie Mueller, San Jose, Calif.

When you pick up a prescription at your pharmacy, always ask your pharmacist to double check the contents of the container to be certain that it contains the correct medication.
Submitted by John Wickenden, MD, Rockport, Maine

Before the procedure, ask the surgeon which products of which companies will be used during procedure. Ask why these products will be used in such procedure. Ask about the statistical performance of the products and in which time frame. This provides the clinical history of the implant or product.
Submitted by Luca Passaggio, MD, Castel San Pietro, Switzerland

Create a medication reference sheet. Include directions and times for use; describe what each pill or liquid looks like and what it is for. Ideally, take a color picture of each pill/liquid medication. Protect the medication list in a plastic sheet. Bring the list with you to each doctor visit. Update the list with every medication change. Give a copy to your pharmacists. Purchase a multiple dose weekly medication box and refill it on the same day each week.
Submitted by Teresa T. Philipp, RN, and Mary Ann Holland, RN

Whenever possible, encourage family members to participate, at the initial visit, in the hospital, and post-operatively. They often have good questions that the patient might not think of, particularly those relating to their individual lives. They help assure quality care and avoid problems, in general and when patients are intubated, sleeping, medicated, or just shy. They remind the patient of the plan, or how to do their therapy, or that they need to avoid weight bearing or certain activities. They also may need to know what their role will be, as a supporter, caregiver, driver, or go-between, so that they can help plan and facilitate things in the best way possible. Ask both them and the patient to write questions down. That way, they don't forget when the provider makes rounds or when the office visit is rushed or when they are unable to ask/remember things.
Submitted by Kevin L. Smith, MD, Seattle, Wash.

When a health care provider (physician, nurse, or other) is about to touch you, and you have not first seen him or her wash hands, ask that the individual do so.
Submitted by John Wickenden, MD, Rockport, Maine

External fixateur pins are a menace, particularly if the tips are sharp. Sharp pin tips are a problem because they can cut the patient's other extremity, tear bedding, and even cut a significant other! Therefore we advise our patients to use a short piece of plastic tubing stuck on the end of the pin to keep their pins covered!
Submitted by David Seligson, MD, Louisville, Ky.

When seeing a specialist, there is an urge to have the physician address multiple different complaints related to that specialty beyond the referred complaint. In many cases, instead of receiving a complete evaluation of any one of these ailments, all are addressed to a degree. It is better to get all your questions/concerns answered regarding a single main complaint and return for another appointment, if warranted, for the others.
Submitted by Mark Leber, MD, Indianapolis, Ind.

Keep aware and alert. Keep tabs on your soul, intellect and emotions-all housed by the body-and your body, in that order. Be aware of what you are doing, what is being done to you and by whom at all times possible. Keep a book of Psalms(King David's Tehillim) with you at all times; read it when possible and establish regular times to read from it. This will help to keep you aligned with God. When you are seen by hospital staff, including physicians, this may engender love and fear of God in them, never a bad thing. Peace.
Submitted by Steven Pearlstein, MD, Coral Springs, Fla.

Medication/Device Safety

Use electronic medical record printable forms with personal written signature for all prescriptions. This insures authenticity and decreases incorrect interpretation of the medication.
Submitted by Charles P. Dahl, MD, Bismarck, N.D.

Write orders and prescriptions legibly to avoid miscommunication or confusion.
Submitted by Arvind D. Nana, MD, Fort Worth, Texas

When applying an elastic wrap to the ankle foot, make sure the heel is not included in the wrap to help prevent accidental falls. The heel is the most common place the foot loses grip when one falls. If the heel is not wrapped, it has better grip. I have not found a loss of effectiveness in ankle support or compression with this technique.
Submitted by Michael Grillot,MD, Bolivar, Mo.

All casts applied to acute fractures should be bivalved. This was relatively easy in the plaster cast days, when an aluminum strip, ¾-inch wide was placed over the stocinette, and then the cast was applied. Following that a scalpel was used to cut the cast, along the front of the leg or the front of the humerus and the radial side of the forearm. Today, it will be necessary to cut the cast with a saw, again, using a metal strip to protect the underlying skin. It is important that the cast be cut completely, down to the strip, so when the parent or patient calls to report unrelenting pain, you can have them twist a wide blade screwdriver to relieve the pressure. Cutting a cast with very little padding under it, when the skin is tight under the cast, is a painful procedure and is obviated by splitting the cast immediately after applying it.
Submitted by Milton A. Claassen, MD, Newton, Kan.

When treating a distal radius fractures with external fixation, cover the half-pins and external fixator rail with an ABD pad as part of the postoperative dressing. This prevents the patient from injuring him/herself and recovery room nurses in the immediate postoperative period. It also prevents injury to the patient and family members during the early post-operative period until the patient becomes accustomed to having the fixator in place.
Submitted by Jeffrey Lawton, MD, Cleveland, Ohio

Give patients walking devices such as a walker or crutches three months before scheduled surgery. Provide them with occupational therapy for the devices. Have them practice using the device three to four times a week for about 15 to 20 minutes. By the time they have surgery, using the device will be easier and cause less discomfort. Patients will have an easier time getting around, lowering the risk of accidents and also allow them to have an easier time with the recovery. Many patients have a difficult time mastering the devices when they are not given the opportunity to practice with them, especially if they have never even seen them until after the surgery. For example, if the patient has already mastered using crutches to get up and down stairs, when it comes time to do this activity after surgery, they only have to deal with the precautions from the surgery.
Submitted by Lynn Flynn, Charlton, Mass.