EORNA2022_Abstract Book

Stavanger, Norway | 12 - 15 May 2022 10th EORNA Congress Parallel Sessions 23 OP21 Rolling out training in risk management and open disclosure in the operating room S. Boland1, T. Donnelly2 1Sligo University Hospital, General Theatre, Sligo, Ireland, 2Sligo University Hospital, Sligo, Ireland It is now acknowledged that, while most things are done for most patients most of the time, process failures, cognitive impairment/human error, and less than optimal teamwork result in inconsistencies of care and adverse outcomes. Dr Gawande, ‘We look for medicine to be an orderly field of knowledge and procedure but it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals and at the same time lives on the line. In surgery, you couldn’t have people who are more specialised and you couldn’t have people who are better trained. And yet we see unconscionable levels of death, disability that could be avoided. Every year, an estimated 234 million surgeries are performed globally. Of these, an estimated seven million complications and one million deaths occur; half of which is thought to be preventable. The scale and typology of surgical harm common to the world’s health systems was first identified in 2004, due to returns to the World Health Organisation (WHO) and data analysis from some 54 countries. It was calculated that, of an estimated 187 million major procedures conducted worldwide per annum, 3-16% resulted in major complications and with disturbing death rates (Weiser et al 2008). Risk management is essential in modern healthcare. It promotes a transparent system of care where error is identified, analysed, controlled and evaluated. Reporting an incident or a near miss is the corner stone of risk management. Risk management incorporates and promotes the essential concept of open disclosure. Open disclosure is an open, consistent approach to communicating with patients when things go wrong in healthcare. The authors introduced an education programme upskilling staff on risk management, open disclosure and reporting. “To err is human, to cover up is unforgivable and to fail to learn is inexcusable”. OP22 Surgical counting, a tool for patient safety during surgery: a qualitative study of the experience of operating room nurses W. Oksavik1, C. Heen2, K. Heggdal1 1Lovisenberg Diaconal University College, Oslo, Norway, 2Oslo University Hospital, Department of Operating Services, Oslo, Norway Background: Retention of surgical items in patients after completing surgery is a significant problem that causes harm and suffering to the patients and, in some cases, death. The operating room nurses have an important role in performing the surgical count correctly and to prevent adverse events. Aim: The purpose of this study was to attain knowledge of the operating room nurses’ practice and experiences in performing the surgical count and how they reflect on patient safety. Method: A qualitative approach was chosen for this study. Field observations of 12 surgical teams followed by semistructured interviews of the scrub nurses were conducted in 3 hospitals in Norway in 2017. Content analysis guided the analysis of data. Results: Three main themes were identified: Variation in the implementation of the procedure; Perceiving presence and situational awareness; Disrespectful attitudes and near-miss events. The analysis shows that there is variation in the implementation of the counting procedure, and uncertainty regarding the existence and use of guidelines. At the same time, the operating room nurses were sentient present and adapted their practice with their own understanding of the situation. They gave examples of disrespectful attitude from other team members in relation to the counting procedure, and describe that near-miss events occur. The findings are contradictory. The operating room nurses express uncertainty regarding execution of the procedure, and the observations showed great variation. Instruments got lost in 2 of the 12 observed operations. Conclusion: The study provides a basis for strengthening the education of operating room nurses regarding the recommended guidelines for surgical counting. Furthermore, to guide the operating room nurses to be resilient and show authority when it comes to practicing the counting procedure, and dare to report events that may threaten patient safety.

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