Cerrahide Hasta Güvenliği
Özet
Cerrahi hastasının güvenliği, küresel olarak sağlık hizmetlerinin kalitesini gösteren temel ilkelerden biridir. Cerrahi hastalarında güvenli cerrahinin sağlanması, istenmeyen olayların önlenmesi için önemlidir. Cerrahide hasta güvenliğini tehdit eden unsurlar arasında yanlış taraf cerrahisi, yabancı cisim unutulması, cerrahi duman, basınç yaralanmaları, hasta düşmeleri yer almaktadır. Cerrahinin her aşamasında ameliyat öncesi, sırası ve sonrasında hemşireler ile cerrahi ekibin hasta güvenliğini sağlama ve istenmeyen olayları önleme konusunda önemli sorumlulukları bulunmaktadır. Cerrahi hastalarında hasta güvenliğini tehdit eden unsurlar değerlendirilmeli ve gerekli önleme politikaları geliştirilmelidir.
Surgical patient safety is one of the key principles that indicate the quality of healthcare globally. Ensuring safe surgery in surgical patients is important to prevent adverse events. Factors that threaten patient safety in surgery include wrong-side surgery, forgotten foreign body, surgical smoke, pressure injuries, and patient falls. At every stage of surgery, nurses and the surgical team have important responsibilities to ensure patient safety and prevent adverse events before, during, and after surgery. Factors that threaten patient safety in surgical patients should be evaluated and necessary prevention policies should be developed.
Referanslar
World Health Organization. Patient safety 2019. (10/05/2024 tarihinde https://www.who.int/news-room/fact-sheets/detail/patient-safety adresinden ulaşılmıştır)
Henriques AHB, Costa SS, Lacerda JS. Nursing care in surgical patient safety. Cogitare Enferm; 2016;21(4):1–9.
World Health Organization. WHO guidelines for safe surgery, safe surgery saves lives 2009 (10/05/2024 tarihinde http://whqlibdoc.who.int/publications/2009/9789241598552_eng. Pdf 2009 adresinden ulaşılmıştır).
TC Sağlık Bakanlığı, Sağlık Hizmetleri Genel Müdürlüğü Sağlıkta Kalite ve Akreditasyon Daire Başkanlığı. Güvenli Cerrahi Uygulama Rehberi, 2 .Baskı. Ankara: Ankara, Mattek Matbaacılık Basım Yayın Tan.Tic.San.Ltd.Şti;2015
Ramírez-Torres CA, Pedraz-Marcos A, Maciá-Soler ML, et al. Scoping Review of Strategies Used to Implement the Surgical Safety Checklist. AORN J; 2021 28;113(6):610–619.
Joint Commission; The Joint Commission. Universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. Oakbrook Terrace (IL) 2009. (22/05/2024 tarihinde at:http://www.jointcommission.org/PatientSafety/UniversalProtocol. adresinden ulaşılmıştır).
The Joint Commission. Sentinel event statistics released for 2020, 2021. (22/05/2024 tarihinde https://www.jointcommission.org/resources/news-and-multimedia/newsletters/ newsletters/joint-commission-online/march-24-2021/sentinel-event-statistics- released-for-2020/#.YkDVEHrMKUk adresinden ulaşılmıştır).
Ross J. Risks Remain for Wrong-Site Surgeries. Journal of PeriAnesthesia Nursing; 2022;37(2):277–279. Doi:10.1016/j.jopan.2022.01.007
Health Research & Educational Trust and Joint Commission Center for Transforming Healthcare. (2014, August). Reducing the risks of wrong-site surgery: Safety practices from The Joint Commission Center for Transforming Healthcare project. Chicago, IL: Health Research & Educational Trust (24/05/2024 tarihinde at www.hpoe.org. Adresinden ulaşılmıştır).
AORN. Wrong Surgeries Up 26% in 2023. (22/05/2024 tarihinde https://www.aorn.org/article/wrong-surgeries-up-26--in-2023 adresinden ulaşılmıştır).
Tupper C, Doyal A. OSHA Fire Safety. In StatPearls [Internet]. StatPearls Publishing, 2023.
Fisher M. Prevention of Surgical Fires: A Certification Course for Healthcare Providers. AANA Journal; 2015;83(4):271–274.
Mehta SP, Bhananker SM, Posner KL, et al. Operating room fires: a closed claims analysis. Anesthesiology; 2013;118(5):1133–1139. DOİ: 10.1097/ALN.0b013e31828afa7b
JCI. Updated surgical fire prevention for the 21st centruy, 2023. (26/05/2024) tarihinde https://www.jointcommission.org/-/media/tjc/newsletters/sea-68-surgical-fire-prevention2-10-9-23-final.pdf adresinden ulaşılmıştır).
Akhtar N, Ansar F, Baig M, et al. Airway fires during surgery: Management and prevention. J Anaesthesiol Clin Pharmacol; 2016;32(1):109-111. DOI: 10.4103/0970-9185.175710
The Joint Commission. Environment of Care (EC) News. Making electrosurgery safer. EC News. 2024;27(2):13–6.
AORN. Updated Fire Safety Tool Kit 2024. (26/05/2024 tarihinde https://www.aorn.org/article/updated-fire-safety-tool-kit adresinden ulaşılmıştır).
Sirihorachai R, Saylor KM, Manojlovich M. Interventions for the Prevention of Retained Surgical Items: A Systematic Review. World J Surg.; 2022, 12;46(2):370–81. DOİ: 10.1007/s00268-021-06370-3
Williams TL, Tung DK, Steelman VM, et al. Retained Surgical Sponges: Findings from Incident Reports and a Cost-Benefit Analysis of Radiofrequency Technology, J Am Coll Surg.; 2014;219(3):354–64. DOI: 10.1016/j.jamcollsurg.2014.03.052
Takahashi K, Fukatsu T, Oki S, et al. Characteristics of retained foreign bodies and near-miss events in the operating room: a ten-year experience at one institution. Journal of Anesthesia, 2023;8;37(1):49–55. Doi:10.1007/s00540-022-03127-7
Sirihorachai R, Saylor KM, Manojlovich M. Interventions for the Prevention of Retained Surgical Items: A Systematic Review, World J Surg; 2022:12;46(2):370–81. DOİ: 10.1007/s00268-021-06370-3
Steelman VM, Shaw C, Shine L, et al. Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentinel Events and Contributing Factors. The Joint Commission Journal on Quality and Patient Safety, 2019; 45(4):249–58. DOİ: 10.1016/j.jcjq.2018.09.001
AORN. Guideline for prevention of unintentionally retained surgical items. In: Guidelines for Perioperative Practice . Denver, CO: AORN; 2022; 827–94.
The Joint Commission. Strategies to prevent URFOs. (22/05/2024 tarihinde https://www.jointcommission.org/-/media/tjc/newsletters/quick-safety-20-update-5-3-22.pdf adresinden ulaşılmıştır).
Dixon K, Dasgupta P, Vasdev N. A systematic review of the harmful effects of surgical smoke inhalation on operating room personnel. Health Sciences Review; 2023;6:1-9. DOİ: 10.1016/j.hsr.2023.100077
Zhou Y zhi, Wang C qun, Zhou M hua, et al. Surgical smoke: A hidden killer in the operating room. Asian J Surg; 2023;46(9):3447–54. DOİ: 10.1016/j.asjsur.2023.03.066
Liu Y, Zhao M, Shao Y, et al. Chemical composition of surgical smoke produced during the loop electrosurgical excision procedure when treating cervical intraepithelial neoplasia. World J Surg Oncol;2021;9:19(1):3-8 DOİ: 10.1186/s12957-021-02211-8
Vortman R, McPherson S, Cecilia Wendler M. State of the Science: A Concept Analysis of Surgical Smoke. AORN Journal, 2021; 30;113(1):41–51. DOİ:10.1002/aorn.13271
Williams K. Guidelines in Practice: Surgical Smoke Safety. AORN J. 2022; 26;116(2):145–59. DOİ: 10.1002/aorn.13745
Ostapovych U, Vortman R. Implementing a Surgical Smoke Evacuation Policy and Procedure: A Quality Improvement Project. AORN J;2022;27;115(2):139–46. DOİ: 10.1002/aorn.13603
AORN. Guideline for surgical smoke safety. . In: Guidelines for Perioperative Practice . Denver, CO: AORN ; 2022: 1107–54.
Fencl JL. Guideline Implementation: Surgical Smoke Safety. AORN J. 2017;26;105(5):488–97. DOİ:10.1016/j.aorn.2017.03.006
Spruce L. Back to Basics: Preventing Perioperative Pressure Injuries. AORN J. 2017; 27;105(1):92–99. DOİ:10.1016/j.aorn.2016.10.018
Speth J. Guidelines in Practice: Prevention of Perioperative Pressure Injury. AORN J. 2023;27;118(1):37–44. DOİ: 10.1002/aorn.13948
Spruce L. Prevention of Perioperative Pressure Injury. AORN J; 2023;27;117(5):317–23. DOİ: 10.1002/aorn.13918
Meehan AJ, Beinlich NR, Hammonds TL. A Nurse-Initiated Perioperative Pressure Injury Risk Assessment and Prevention Protocol. AORN J; 2016;104(6):554–65.
Kozhimala K, Crowley‐Barnett J, Dobbie M, et al. Perioperative Risk Assessment for Skin Injury. AORN J; 2023; 25;118(3):149–56. DOİ: 10.1002/aorn.13985
AORN. AORN Position Statement on Prevention of Perioperative Pressure Injury 2022. (26/05/2024 tarihinde https://www.aorn.org/docs/default-source/guidelines-resources/position-statements/patient-care/posstat-prevpresinj-0303.pdf?sfvrsn=8c9c69b5 adresinden ulaşılmıştır).
Munro CA. The Development of a Pressure Ulcer Risk‐Assessment Scale for Perioperative Patients. AORN J; 2010;92(3):272–87. DOİ: 10.1016/j.aorn.2009.09.035
Lopes CM de M, Haas VJ, Dantas RAS, et al. Assessment scale of risk for surgical positioning injuries. Rev Lat Am Enfermagem. 2016;24(e2704):1-8. DOİ:10.1590/1518-8345.0644.2704
Meehan AJ, Beinlich NR, Bena JF, et al. Revalidation of a Perioperative Risk Assessment Measure for Skin. Nurs Res; 2019;68(5):398–404. DOI: 10.1097/NNR.0000000000000362
Scott Triggers. Perioperative pressure injury prevention program (30/05/2024 tarihide https://scotttriggers.com adresinden ulaşılmıştır).
Shi C, Dumville JC, Cullum N, et al. Beds, overlays and mattresses for preventing and treating pressure ulcers: an overview of Cochrane Reviews and network meta-analysis. Cochrane Database of Systematic Reviews; 2021;16;2021(8):1-137. DOİ: 10.1002/14651858.CD013761.pub2
Kimsey DB. A Change in Focus: Shifting From Treatment to Prevention of Perioperative Pressure Injuries. AORN J; 2019;27;110(4):379–393. DOİ:10.1002/aorn.12806
The Joint Commission. Summary Data of Sentinel Events Reviewed by The Joint Commission. Oakbrook Terrace, IL: The Joint Commission; (30/05/2024 tarihinde https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/annual-se-report-2021.pdf adresinden ulaşılmıştır).
Hauk L. Guideline for safe patient handling and movement. AORN J; 2018;29;107(6). DOİ:10.1002/aorn.12287
Croke L. Guideline for Safe Patient Handling and Movement. AORN J; 2024;27;119(1). DOİ:10.1002/aorn.14069
Kobayashi K, Ando K, Suzuki Y, Inagaki Y., Nagao Y., Ishiguro N., et al. Characteristics of outpatient falls that occurred in hospital. Nagoya J Med Sci; 2018;80:417–22. DOİ: DOİ:10.18999/nagjms.80.3.417
Croke L. Preventing Falls Among Perioperative Patients. AORN J;2022;27;116(5). DOİ: 10.1002/aorn.13816
Prielipp RC, Weinkauf JL, Esser TM, et al. Falls From the O.R. or Procedure Table. Anesth Analg;2017;125(3):846–851. DOİ:10.1213/ANE.0000000000002125
Kronzer VL, Wildes TM, Stark SL, et al. Review of perioperative falls. Br J Anaesth; 2016;117(6):720–32. DOİ:10.1093/bja/aew377
Patient Safety Network. Falls 2019 (30/05/2024 tarihinde https://psnet.ahrq.gov/primer/falls adresinden ulaşılmıştır).
Speth J. Guidelines in Practice: Positioning the Patient. AORN J; 2023;26;117(6):384–90. DOİ: 10.1002/aorn.13929
Referanslar
World Health Organization. Patient safety 2019. (10/05/2024 tarihinde https://www.who.int/news-room/fact-sheets/detail/patient-safety adresinden ulaşılmıştır)
Henriques AHB, Costa SS, Lacerda JS. Nursing care in surgical patient safety. Cogitare Enferm; 2016;21(4):1–9.
World Health Organization. WHO guidelines for safe surgery, safe surgery saves lives 2009 (10/05/2024 tarihinde http://whqlibdoc.who.int/publications/2009/9789241598552_eng. Pdf 2009 adresinden ulaşılmıştır).
TC Sağlık Bakanlığı, Sağlık Hizmetleri Genel Müdürlüğü Sağlıkta Kalite ve Akreditasyon Daire Başkanlığı. Güvenli Cerrahi Uygulama Rehberi, 2 .Baskı. Ankara: Ankara, Mattek Matbaacılık Basım Yayın Tan.Tic.San.Ltd.Şti;2015
Ramírez-Torres CA, Pedraz-Marcos A, Maciá-Soler ML, et al. Scoping Review of Strategies Used to Implement the Surgical Safety Checklist. AORN J; 2021 28;113(6):610–619.
Joint Commission; The Joint Commission. Universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. Oakbrook Terrace (IL) 2009. (22/05/2024 tarihinde at:http://www.jointcommission.org/PatientSafety/UniversalProtocol. adresinden ulaşılmıştır).
The Joint Commission. Sentinel event statistics released for 2020, 2021. (22/05/2024 tarihinde https://www.jointcommission.org/resources/news-and-multimedia/newsletters/ newsletters/joint-commission-online/march-24-2021/sentinel-event-statistics- released-for-2020/#.YkDVEHrMKUk adresinden ulaşılmıştır).
Ross J. Risks Remain for Wrong-Site Surgeries. Journal of PeriAnesthesia Nursing; 2022;37(2):277–279. Doi:10.1016/j.jopan.2022.01.007
Health Research & Educational Trust and Joint Commission Center for Transforming Healthcare. (2014, August). Reducing the risks of wrong-site surgery: Safety practices from The Joint Commission Center for Transforming Healthcare project. Chicago, IL: Health Research & Educational Trust (24/05/2024 tarihinde at www.hpoe.org. Adresinden ulaşılmıştır).
AORN. Wrong Surgeries Up 26% in 2023. (22/05/2024 tarihinde https://www.aorn.org/article/wrong-surgeries-up-26--in-2023 adresinden ulaşılmıştır).
Tupper C, Doyal A. OSHA Fire Safety. In StatPearls [Internet]. StatPearls Publishing, 2023.
Fisher M. Prevention of Surgical Fires: A Certification Course for Healthcare Providers. AANA Journal; 2015;83(4):271–274.
Mehta SP, Bhananker SM, Posner KL, et al. Operating room fires: a closed claims analysis. Anesthesiology; 2013;118(5):1133–1139. DOİ: 10.1097/ALN.0b013e31828afa7b
JCI. Updated surgical fire prevention for the 21st centruy, 2023. (26/05/2024) tarihinde https://www.jointcommission.org/-/media/tjc/newsletters/sea-68-surgical-fire-prevention2-10-9-23-final.pdf adresinden ulaşılmıştır).
Akhtar N, Ansar F, Baig M, et al. Airway fires during surgery: Management and prevention. J Anaesthesiol Clin Pharmacol; 2016;32(1):109-111. DOI: 10.4103/0970-9185.175710
The Joint Commission. Environment of Care (EC) News. Making electrosurgery safer. EC News. 2024;27(2):13–6.
AORN. Updated Fire Safety Tool Kit 2024. (26/05/2024 tarihinde https://www.aorn.org/article/updated-fire-safety-tool-kit adresinden ulaşılmıştır).
Sirihorachai R, Saylor KM, Manojlovich M. Interventions for the Prevention of Retained Surgical Items: A Systematic Review. World J Surg.; 2022, 12;46(2):370–81. DOİ: 10.1007/s00268-021-06370-3
Williams TL, Tung DK, Steelman VM, et al. Retained Surgical Sponges: Findings from Incident Reports and a Cost-Benefit Analysis of Radiofrequency Technology, J Am Coll Surg.; 2014;219(3):354–64. DOI: 10.1016/j.jamcollsurg.2014.03.052
Takahashi K, Fukatsu T, Oki S, et al. Characteristics of retained foreign bodies and near-miss events in the operating room: a ten-year experience at one institution. Journal of Anesthesia, 2023;8;37(1):49–55. Doi:10.1007/s00540-022-03127-7
Sirihorachai R, Saylor KM, Manojlovich M. Interventions for the Prevention of Retained Surgical Items: A Systematic Review, World J Surg; 2022:12;46(2):370–81. DOİ: 10.1007/s00268-021-06370-3
Steelman VM, Shaw C, Shine L, et al. Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentinel Events and Contributing Factors. The Joint Commission Journal on Quality and Patient Safety, 2019; 45(4):249–58. DOİ: 10.1016/j.jcjq.2018.09.001
AORN. Guideline for prevention of unintentionally retained surgical items. In: Guidelines for Perioperative Practice . Denver, CO: AORN; 2022; 827–94.
The Joint Commission. Strategies to prevent URFOs. (22/05/2024 tarihinde https://www.jointcommission.org/-/media/tjc/newsletters/quick-safety-20-update-5-3-22.pdf adresinden ulaşılmıştır).
Dixon K, Dasgupta P, Vasdev N. A systematic review of the harmful effects of surgical smoke inhalation on operating room personnel. Health Sciences Review; 2023;6:1-9. DOİ: 10.1016/j.hsr.2023.100077
Zhou Y zhi, Wang C qun, Zhou M hua, et al. Surgical smoke: A hidden killer in the operating room. Asian J Surg; 2023;46(9):3447–54. DOİ: 10.1016/j.asjsur.2023.03.066
Liu Y, Zhao M, Shao Y, et al. Chemical composition of surgical smoke produced during the loop electrosurgical excision procedure when treating cervical intraepithelial neoplasia. World J Surg Oncol;2021;9:19(1):3-8 DOİ: 10.1186/s12957-021-02211-8
Vortman R, McPherson S, Cecilia Wendler M. State of the Science: A Concept Analysis of Surgical Smoke. AORN Journal, 2021; 30;113(1):41–51. DOİ:10.1002/aorn.13271
Williams K. Guidelines in Practice: Surgical Smoke Safety. AORN J. 2022; 26;116(2):145–59. DOİ: 10.1002/aorn.13745
Ostapovych U, Vortman R. Implementing a Surgical Smoke Evacuation Policy and Procedure: A Quality Improvement Project. AORN J;2022;27;115(2):139–46. DOİ: 10.1002/aorn.13603
AORN. Guideline for surgical smoke safety. . In: Guidelines for Perioperative Practice . Denver, CO: AORN ; 2022: 1107–54.
Fencl JL. Guideline Implementation: Surgical Smoke Safety. AORN J. 2017;26;105(5):488–97. DOİ:10.1016/j.aorn.2017.03.006
Spruce L. Back to Basics: Preventing Perioperative Pressure Injuries. AORN J. 2017; 27;105(1):92–99. DOİ:10.1016/j.aorn.2016.10.018
Speth J. Guidelines in Practice: Prevention of Perioperative Pressure Injury. AORN J. 2023;27;118(1):37–44. DOİ: 10.1002/aorn.13948
Spruce L. Prevention of Perioperative Pressure Injury. AORN J; 2023;27;117(5):317–23. DOİ: 10.1002/aorn.13918
Meehan AJ, Beinlich NR, Hammonds TL. A Nurse-Initiated Perioperative Pressure Injury Risk Assessment and Prevention Protocol. AORN J; 2016;104(6):554–65.
Kozhimala K, Crowley‐Barnett J, Dobbie M, et al. Perioperative Risk Assessment for Skin Injury. AORN J; 2023; 25;118(3):149–56. DOİ: 10.1002/aorn.13985
AORN. AORN Position Statement on Prevention of Perioperative Pressure Injury 2022. (26/05/2024 tarihinde https://www.aorn.org/docs/default-source/guidelines-resources/position-statements/patient-care/posstat-prevpresinj-0303.pdf?sfvrsn=8c9c69b5 adresinden ulaşılmıştır).
Munro CA. The Development of a Pressure Ulcer Risk‐Assessment Scale for Perioperative Patients. AORN J; 2010;92(3):272–87. DOİ: 10.1016/j.aorn.2009.09.035
Lopes CM de M, Haas VJ, Dantas RAS, et al. Assessment scale of risk for surgical positioning injuries. Rev Lat Am Enfermagem. 2016;24(e2704):1-8. DOİ:10.1590/1518-8345.0644.2704
Meehan AJ, Beinlich NR, Bena JF, et al. Revalidation of a Perioperative Risk Assessment Measure for Skin. Nurs Res; 2019;68(5):398–404. DOI: 10.1097/NNR.0000000000000362
Scott Triggers. Perioperative pressure injury prevention program (30/05/2024 tarihide https://scotttriggers.com adresinden ulaşılmıştır).
Shi C, Dumville JC, Cullum N, et al. Beds, overlays and mattresses for preventing and treating pressure ulcers: an overview of Cochrane Reviews and network meta-analysis. Cochrane Database of Systematic Reviews; 2021;16;2021(8):1-137. DOİ: 10.1002/14651858.CD013761.pub2
Kimsey DB. A Change in Focus: Shifting From Treatment to Prevention of Perioperative Pressure Injuries. AORN J; 2019;27;110(4):379–393. DOİ:10.1002/aorn.12806
The Joint Commission. Summary Data of Sentinel Events Reviewed by The Joint Commission. Oakbrook Terrace, IL: The Joint Commission; (30/05/2024 tarihinde https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/annual-se-report-2021.pdf adresinden ulaşılmıştır).
Hauk L. Guideline for safe patient handling and movement. AORN J; 2018;29;107(6). DOİ:10.1002/aorn.12287
Croke L. Guideline for Safe Patient Handling and Movement. AORN J; 2024;27;119(1). DOİ:10.1002/aorn.14069
Kobayashi K, Ando K, Suzuki Y, Inagaki Y., Nagao Y., Ishiguro N., et al. Characteristics of outpatient falls that occurred in hospital. Nagoya J Med Sci; 2018;80:417–22. DOİ: DOİ:10.18999/nagjms.80.3.417
Croke L. Preventing Falls Among Perioperative Patients. AORN J;2022;27;116(5). DOİ: 10.1002/aorn.13816
Prielipp RC, Weinkauf JL, Esser TM, et al. Falls From the O.R. or Procedure Table. Anesth Analg;2017;125(3):846–851. DOİ:10.1213/ANE.0000000000002125
Kronzer VL, Wildes TM, Stark SL, et al. Review of perioperative falls. Br J Anaesth; 2016;117(6):720–32. DOİ:10.1093/bja/aew377
Patient Safety Network. Falls 2019 (30/05/2024 tarihinde https://psnet.ahrq.gov/primer/falls adresinden ulaşılmıştır).
Speth J. Guidelines in Practice: Positioning the Patient. AORN J; 2023;26;117(6):384–90. DOİ: 10.1002/aorn.13929
