Melzi Resources

When patients enter a medical facility, they’re putting their care, and often their lives, in the hands of medical staff. OR nurses often shoulder an immense amount of this responsibility, being accountable for providing proper care and ensuring a patient’s safety to the best of their ability during intense and sometimes exhausting conditions. Especially during complicated surgeries, unexpected challenges like needle miscounts can hinder effective care, altering patient outcomes and risking severe repercussions for the patient, the OR staff, and the medical facility itself, such as surgery malpractice lawsuits. Implementing proactive measures can mitigate these risks and help OR nurses prepare for potential challenges and hazards, reducing their impact.

Patient safety is a primary objective in healthcare, but it’s also a complicated and multifaceted issue. By understanding the risks patients experience when receiving care and the best ways to mitigate those risks, OR nurses can reduce the impact of errors like needle miscounts and other potential complications like retained surgical items (RSIs), maximize safety in the healthcare facility, and improve patient outcomes.

Having recently wrapped up this year’s Association of OR Nurses (AORN) Conference, now is the perfect time to step back and reevaluate patient safety protocols. Read on to better understand patient safety and what you can do to improve it in your facility.

What Does Patient Safety Entail?

Patient safety is not a straightforward issue. Patients receiving treatment at a hospital or surgery center face risks of complications during or after receiving care. Identified or unidentified pre-existing conditions, errors in recording a patient’s medications, and new symptoms that arise during treatment can put patients at higher risk of developing complications that impact recovery. Patient safety awareness aims to ensure these complications, and any others that may arise, are managed safely, responsibly, and as effectively as possible.

To effectively increase patient safety, you must first raise awareness and establish best practices and protocols that all staff is trained to comply with. These protocols can include simple tasks like handwashing or cleaning and should extend to more serious responsibilities like administering medication, executing accurate surgical counts, and performing medical procedures. Staff should be made aware and trained on these best practices and held accountable for following them.

Major Sentinel Events

Sentinel events are unexpected instances or variations in the routine care of a patient that can have serious repercussions on the patient’s health and well-being. These events are often preventable with proper patient safety awareness and established procedures. One of the primary goals of increased patient safety awareness for OR nurses is reducing these “never events,” the health risks they pose to patients, the liability risks they pose to facilities, and the reputational risks they pose to medical professionals. There are several sentinel events that healthcare providers must report. Let’s look at a few of the most common.

Falls

When a patient is injured in a fall on hospital grounds, it needs to be reported. Falls can be surprisingly dangerous even for healthy individuals, but when your body is compromised, a fall can be devastating.

Misdiagnosis or Delayed Treatment

Incorrect diagnoses or delays in treatment that lead to patient harm must also be reported. It can be difficult to diagnose some patients, and many misdiagnoses are inadvertent. But when a misdiagnosis or delay in treatment results from a failure to test appropriately or do the required due diligence, it must be reported.

Retained Surgical Items

During surgeries, especially complicated surgeries like transplants that require multiple shift changes and high needle counts, miscount events can be common. Miscounts can lead to retained surgical items or RSIs. RSIs constitute a significant risk and must be reported. They can lead to serious adverse effects for the patient but also major liability concerns and reputational damage for the facility and surgeon. Proper surgical counting, established lost sharp protocols, and patient safety awareness can prevent RSIs.

Wrong-Site Surgery

The hospital must report when surgery is performed on the wrong part of the patient’s body or the wrong patient. Proper procedures and careful adherence to those procedures can help mitigate the risks of wrong surgeries.

Medication Errors

Healthcare facilities must also report preventable medication errors. Whether the medication is in the control of a healthcare professional or the patient, any inappropriate use or patient harm that results is considered a sentinel event.

The Role of Patients and Technology

One powerful way to increase patient safety is to involve the patients themselves. You can ensure patients understand their diagnosis, treatment, and medications by encouraging them to actively participate in their care, advocate for themselves, report any safety issues or concerns, and ask questions.

Utilizing the right tools and technology can also quickly and efficiently improve patient safety. Whether it’s digitizing patient records to ensure easy access to accurate information, using patient safety software that can alert healthcare providers to certain risks, or implementing OR technology that assists with surgical counts to ensure there’s no metal left in the body after surgery, tools are often an OR nurse’s last line of defense for preventing disaster.

Choosing the Right Patient Safety Technology

The best tools and technology for patient safety are easy to use, quickly deployed, and effective. Many hospitals already utilize radiofrequency technology to improve their counting protocols for surgical sponges. These devices help reduce the risk of some retained surgical items. But they don’t assist with locating metallic instrument fragments, guidewires, or needles that can be lost in a patient during surgery.

There is, however, a tool that surgeons and OR nurses are adopting to supplement their current lost sharp and needle miscount protocols: the Melzi™ Sharps Finder™¹. The Melzi Sharps Finder is designed to help medical professionals prevent retained surgical items by detecting lost sharps that may be invisible to X-ray, allowing for quick retrieval without prolonged anesthesia for patients².

Explore our website to learn more about Melzi and discover why OR nurses all over the U.S. have come to rely on the Melzi Sharps Finder as a necessary OR tool to manage miscounts.

If you’re ready to enhance patient safety and reduce RSI risks, contact Melzi today to request a product demo.

Reference:

1. Weprin, S. A., Meyer, D., Li, R., Carbonara, U., Crocerossa, F., Kim, F. J., Autorino, R., Speich, J. E., Klausner, A. P. (2021, April 3). Incidence and or team awareness of “near-miss” and retained Surgical Sharps: A national survey on United States Operating Rooms. Patient Safety in Surgery.
2. Adams, Ph.D.., J Noel, Ph.D. (2022) Needle Size and Detectability Study. (Available upon request)