Page 1


The Aligning practice with policy to improve

patient care

Volume 7, Issue 1

Myrna Chang


PerforMAX scrubs

Covered Arms Are Compliant Arms

Part of Medline’s line of products.


Naomi Judd

Talk to your facility’s Medline rep or visit to find out more about PerforMAX scrubs.

©2012 Medline Industries, Inc. PerforMAX and greensmart are trademarks and Medline is a registered trademark of Medline Industries, Inc.

Collaboration Communication


The latest AORN and OSHA guidelines recommend that OR nurses who aren’t in gowns should wear long sleeves.

These sleeves are like the finest athletic undergear: cool, supportive and totally breathable. And because they’re PerforMAX, you get a fashionable layered look that’s comfortable and functional all shift long.



Medline innovation triumphs again.

PerforMAX scrubs added an inner sleeve to keep arms covered without dangling cuffs—like on jackets—to contaminate sterile fields.

Innovative scrub design enhances patient safety

Tragic Illness Leads to a Healthcare Safety Crusade MKT212065 / LIT1012 / 30M / QG5


Pink Glove Dance II Video Competition! Page 82


Preventing Surgical Fires

Forms & Tools

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Myrna Chang, DHA, RN, CNOR Myrna worked in collaboration with Medline to design an innovative new line of the industry’s first long-sleeved scrubs. The design was a response to AORN and OSHA guidelines, which advise non-scrubbed personnel to wear long sleeves in the OR to prevent skin shedding, which can lead to surgical site infection. Source: AORN Fire Safety Tool Kit. Copyright ©AORN, Inc. Denver, CO; 2011. All rights reserved. Reprinted with permission.

Aligning practice with policy to improve patient care 99

Editor Sue MacInnes, RD Senior Writer


Carla Esser Lake Creative Director Michael A. Gotti Clinical Team Jayne Barkman, BSN, RN, CNOR Lorri Downs, BSN, MS, RN, CIC Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA Kimberly Haines, RN, Certified OR Nurse Rebecca McPherson, MSN, RN Angel Trichak, BSN, RN, CNOR Perioperative Advisory Board Garry Crawford, MS, RN, CNOR Norman Regional Health System, Oklahoma Evangeline Dennis, RN, BSN, CNOR, CMLSO Spivey Station Surgery Center, Georgia Linda Groah, MSN, RN, CNOR, NEA-BD, FAAN Association of PeriOperative Registered Nurses, Colorado Darvina L. Heichemer, BSN, CNOR Gwinnett Medical Center – Duluth, Georgia


Developing and Launching a Long-Sleeved Scrub: Q&A with Myrna Chang of California’s O’Connor Hospital and Jennifer Walrich of Medline.


Targeting: Wrong Site Surgery Risks. Evidencebased, Innovative, new tool hits the bullseye to help reduce this never event.

Vivienne P Kaplan, RN Anaheim Regional Medical Center, California Colleen Mattioni, MBA, RN, CNOR Hospital of the University of Pennsylvania, Pennsylvania Julieann McIntyre, MSN, RN, CNOR South Shore Hospital, Massachusetts Susan A Miller, MSN, RN, CNOR St. Luke’s Hospital, Missouri Susan S Phillips, MSH, RN, CNOR UNC Hospitals, North Carolina Jo Quetsch, MA, RN, NE-BC Providence Sacred Heart Medical Center, Washington Eleonora Shapiro, BSN, MHA, CNOR Mount Sinai Medical Center, New York Pat Thornton, MS, RN, CNOR Southern Regional Medical Center, Georgia Judith A. Townsley, MSN, RN, CPAN Christiana Care Health System, Delaware Pat Thornton, MS, RN, CNOR Southern Regional Medical Center, Georgia Judith A. Townsley, MSN, RN, CPAN Christiana Care Health System, Delaware


Mayo Clinic: Communication and Teamwork Set Them Apart. A private interview with CEO, Dr. Bill Rupp discussing the culture of safety at Mayo.


Naomi Judd: How Her Tragic Illness Led to a Healthcare Safety Crusade. An interview with this country music icon and registered nurse about her experience with a needlestick.

About Medline Medline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospitals, extended care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than 800 dedicated sales representatives nationwide to support its broad product line and cost management services. ©2012 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

Contents (cont)... Patient Safety

46 Patient Safety News 65 Medication Safety in the Operating Room: What is Your Role?

OR Issues

26 You Have Now Crossed Over into the Gray Zone 63 Exposure to Bloodborne Pathogens 68 Rounding Up Compliance

Visit Medline’s exhibit at the

2012 AORN Congress to learn more about:

q Sterillium Rub q Medline University® EmpOweR education q DVT prophylaxis system q ClearCount RFID sponge counting/tracking device q OctylSeal tissue adhesive q PerforMAX Scrubs q Surgeon’s gloves q IRiS (UVC disinfection) q PerfecTemp patient warming device q Procedural packs - standard and custom q Gold Standard TIME OUT program q Abby – Medline’s newest doll! q CDS q Drapes and gowns q Surgical masks

Visit us at booth #3407!

Page 26

Special Features

7 Breast Cancer Facts 10 Prevention Above All Discoveries Grant Program 47 Lean Tools and Concepts Reduce Waste, Improve Efficiency 75 Judy Pickett: Running for Her Life 80 Medline’s AORN Breast Cancer Awareness Breakfast

Caring for Yourself

Page 47

Page 65

70 Fear: How to Kill it Dead! 86 Healthy Eating: Roasted Vegetables

Forms & Tools

89 One and Only Campaign 91 Sharps Safety Begins with You 92 20 Tips to Help Prevent Medical Errors 95 Six Steps to C. diff Prevention 96 First Aid for Exposure to Blood and Bodily Fluids 99 Know Your Role in Preventing Surgical Fires

Page 70

Page 75

4 The OR Connection

The OR Connection Letter from the Editor

Dear Reader, Here we are once again at Congress. So ... exciting. I think the biggest change that I’ve seen in healthcare over the last few years is transparency and openness. I know we have a long way to go, but I also know that never before have I sat at the table with physician leaders brainstorming on how they can participate in reducing waste, making surgery safer, interacting with patients…and so we are making progress. Let me remind you that progress comes in different stages. One size does not fit all ... think different strokes for different folks. Not a bad thing at all, just a progression. Hospitals are at different stages, but we are all working toward a common goal. I am especially excited because I have had the opportunity to talk to some amazing people that are making a difference in health care. Let’s start with Dr. William Rupp. He is the CEO of Mayo Clinic in Jacksonville, Florida. Dr. Rupp graciously allowed me to interview him on site and then walk the halls of Mayo Clinic with him. A sense of the patient comes first, a sense of pride, a sense of collaboration, a sense of a culture of safety… from the top down. Imagine the CEO walks you around the hospital for an hour and a half so that you take away all the glorious things that Mayo is doing.

lead to mistakes. Read more about the Center for Transforming Healthcare and how collaboration leads to knowledge that helps us understand the triggers and how to correct them.

Then there is Myrna Chang, the Director of Perioperative Services at O’Connor Hospital in San Jose, Calif. What is so special about Myrna? Myrna has recognized for a long time that the traditional scrub wear worn in surgery did not meet the needs of infection control and the patient. Pioneers, or should I say innovators like Myrna, transform what has been to what can be. Learn more about how Myrna has used her experience to help design scrub wear that promotes better infection control techniques.

We continue to learn. We continue to share. Our experiences give us reasons to dig deeper, learn more and change the status quo to a new level of care. Our goal is to EMPOWER healthcare workers by educating, identifying actionable steps or solutions to their challenges, and measuring outcomes. If you haven’t heard of the EMPOWER program…talk to your Medline representative. We are on a mission to help you transform your OR.

Then there is the Joint Commission, working together with hospitals across the nation to define the barriers to wrong site surgery. It is one thing to hypothesize those patterns of behavior that promote poor outcomes. It is another to actually go out in the field and work with providers to identify those behaviors that

Finally, when we survey clinicians across the country, we find that the prevalence of needlestick injuries is staggering. But what is even more staggering is our acceptance that this is part of the job. Naomi Judd sheds some light on how a needlestick injury led to her diagnosis of Hepatitis C, her thoughts and how we can change our mind set of acceptance to intolerance.

Thanks for sharing and being a part of our team.

Sue MacInnes, RD Editor

Contributing Writers Kathleen Bartholomew, MN, RN Partners with Convergent HRS for training staff on how to improve their work relationships by building effective teams, focusing on communication and utilizing best practice. She is a national speaker and author of four books on healthcare culture, communication and leadership. index.cfm?s=Healthcare20 Wolf Rinke, RD, CSP Keynote speaker, seminar leader, management consultant, executive coach and editor of the free electronic newsletter Read and Grow Rich, available at In addition he has authored numerous CDs, DVDs and books including Make It a Winning Life: Success Strategies for Life, Love and Business, Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations. Reach him at William Rupp, MD Before becoming CEO of Mayo Clinic in Jacksonville, Fla., Dr. Rupp served two terms as CEO within Mayo Health System — at Luther Midelfort in Eau Claire, Wisc., and at Immanuel St. Joseph’s in Mankato, Minn. In addition to his administrative responsibilities, Rupp is a former practicing medical oncologist. Mayo Health System is a family of clinics, hospitals and health care facilities serving 70 communities in Minnesota, Iowa and Wisconsin. Naomi Judd, RN Judd found herself a single mother raising two little girls at a young age. She worked several jobs to support her family, including being a nurse, secretary, waitress and clerk, before she and her daughter Wynonna formed The Judds. The group went on to become country music’s most successful mother-daughter duo. Naomi took a long break from her career beginning in 1991 after a diagnosis of Hepatitis C from a needlestick during her nursing days. Melody F. Dickerson, MSN, RN Melody Dickerson is a Center for Transforming Healthcare Project Leader and Master Black Belt in the Department of Robust Process Improvement at The Joint Commission. In this role, she supports the Joint Commission’s activities associated with establishing and sustaining a robust process improvement (RPI) culture.

Jayne Barkman, BSN, RN, CNOR With 29 years of perioperative experience in various roles, including surgical technologist, staff nurse and clinical educator, Ms. Barkman currently works as a clinical nurse consultant.

6 The OR Connection




Death rates from breast cancer have been decreasing since 1999 in women under 50.1

U.S. Breast Cancer Statistics. BreastCancer. org website. Available at: http://www. statistics.jsp. Accessed February 6, 2012.


In 2011, there were more than 2.6 million breast cancer survivors in the U.S.1

....................................... 2

There is a 100% survival rate after treatment for those who are diagnosed and treated during the earliest stage of breast cancer. 2

celebrate Reasons to



fast facts

Breast Cancer Statistics. The Breast Cancer Society, Inc. website. Available at: http:// breastcancerstatistics/. Accessed February 6, 2012.

....................................... 3

 hat are the key W statistics about breast cancer? American Cancer Society website. Available at: http:// Cancer/BreastCancer/ DetailedGuide/breastcancer-key-statistics. Accessed February 6, 2012.

About 1in 8 U.S. women will develop invasive breast cancer in her lifetime.1

Motivation to

fight harder In 2012 about 226,870 new cases of invasive breast cancer will be diagnosed in women3

39,510 women will die from breast cancer in 20123

Breast Cancer Awareness Campaign Aligning practice with policy to improve patient care 7

What keeps you up at night? Health Care Reform

Culture of Safety Accountable Care

SCIP measures

Waste Reduction

Patient-Centered Care

Value-Based Purchasing

Medline is listening.



EMPOWER is a comprehensive methodology to help healthcare leaders transform their OR through education, action, and outcomes. EDUCATION • Safety Survey • New Course Curriculum by Industry Leaders • Customized Medline University Web Page

OUTCOMES • Financial Programs • Outcomes Report • Business Reviews

ACTION Safety Solution Examples Include: • Surgical Site Infections • Retained Objects • Wrong Site Surgery • Needlesticks

Contact your local Medline Representative or call 1-800-Medline to learn how you can build a partnership that goes beyond innovative products and savings to ensure positive, sustainable outcomes tailored to your specific needs.

2012 Prevention Above All Discoveries Grant Program Supporting the adoption of solutions and interventions into everyday practice

In today’s healthcare environment, healthcare-acquired conditions, once considered a “side effect,” are no longer accepted. The government does not accept them, patients are not accepting them and the facilities themselves continually look for ways to build better systems to improve the quality of care. Knowing that clinicians in the field have some of the best ideas for improving care, Medline launched the Prevention Above All Discoveries Grant Program in 2008 as a way to help stimulate the gathering of solid evidence that supports the adoption of solutions into clinical practice. Through this innovative program, Medline has awarded more than $1.1 million in funding to front-line healthcare workers researching evidence-based solutions and interventions for the very conditions that CMS has declared as preventable. Medline is accepting letters of intent from May 1 through June 30, 2012 for the 2012 Prevention Above All Discoveries Grant program and intends to award up to $1 million in grants for research on innovative ideas and evidence-based practices that will improve patient safety and quality of care. Healthcare providers interested in submitting letters of intent can apply for one of two funding categories: Pilot Grants of up to $25,000 for projects that can be completed within six months; or Empirical Study Grants of up to $100,000 for projects completed within 12 months. How to apply for a grant More information about the grant program, as well as a sample letter of intent, can be found at prevention-above-all/grants.asp. To submit a grant letter of intent, contact Toni Marchinski, grant coordinator, at or call 866-941-1998.

10 The OR Connection

“Historically, these research projects are great ideas that could significantly help in the fight against some of the toughest hospital-acquired conditions,” said Andrew Kramer, MD, Head of the Department of Medicine’s Health Care Policy and Research Division at the University of Colorado and Grant Review Committee Chair. “What’s unique about this funding is that it is all going to providers who are on the front lines of health care. The feedback this group gives us is critical to advancing healthcare technology.”

2011 Prevention Above All Discoveries Grant Recipients Title:

CAUTI Prevention Program


Piedmont Healthcare Philanthropy, North Carolina

Principal Investigator:

Monica Tennant & Dee Tucker


Incidence of Falls Among Oncology Patients Who Are Cared for by Family Caregivers within Their Home.


Siteman Cancer Center at Barnes Jewish Hospital, Missouri

Principal Investigator:

Patricia Potter, RN, PhD, FAAN; Marilee Kuhrik RN, PhD; Nancy Kuhrik RN, PhD, Sarah Olsen RN, BSN.


Quick Room Turnaround Time (QRTAT) Ultraviolet Light Disinfection for Decreasing HAI


Ohio State University Hospital, Ohio

Principal Investigator:

Christina Liscynesky, MD & Julie E. Mangino, MD


Warfarin Safety Pilot Program


Foundation for Quality Care, New York

Principal Investigator:

Nancy Merlino Leveille, RN, MS & Darren M. Triller, Pharm.D.


Sensor Technology for Tracking and Displaying Bed Elevation Data for Mechanically Ventilated Patients


University of Iowa Hospital, Iowa

Principal Investigator:

Alberto Maria Segre, Philip Polgreen, Geb Thomas, Ted Herman


Testing Patient Education Handbooks


Good Samaritan Hospital, Pennsylvania

Principal Investigator:

Patricia Donley, RN, MSN, Stephanie Andreozzi, Doctorate in Physical Therapy


Using GRASP as Home Treatment for Upper Extremity (UE) Paresis Post-Stroke


Abbotsford Regional Hospital, Canada

Principal Investigator:

May Chan, B.OT, Janice Eng, Ph.D. PT, OT, Shu-Hyun Jang, M.Sc.OT A Standardized Process of Preoperative Body Cleansing with Comfort Bath速 Cleansing Washcloths


Compared to Sage速 2% Chlorhexidine Gluconate (CHG) Cloths to Reduce Prosthetic Joint Infections at Cambridge Hospital


Cambridge Health Alliance, Harvard Medical Center, Massachusetts

Principal Investigator:

Lou Ann Bruno-Murtha, DO, Virginia Caples, RN, CIC and Diane Lancaster, RN, PhD


Falls Risk Assessment Study


Provena St. Joseph Medical Center, Illinois

Principal Investigator:

Jackie Medland RN, PhD


The Effectiveness of Team Training on Fall Reduction


Wellstar Health System, Georgia

Principal Investigator:

Bethany Robertson, LeeAnna Spiva & Marcia Delk, MD

Aligning practice with policy to improve patient care 11

12 The OR Connection

Developing and Launching a Long-Sleeved Scrub Q&A with Myrna Chang of California’s O’Connor Hospital and Jennifer Walrich by Rob Kurtz

of Medline

Medline launched its new PerforMAX scrub at the Association of Perioperative Registered Nurses’ 59th Annual Congress in New Orleans March 26. The scrub, which Medline says is the industry’s first-ever line of long-sleeved OR scrubs, was designed by Medline and Myrna Chang, DHA, RN, CNOR, director of perioperative services and sterile processing at O’Connor Hospital in San Jose, Calif.

The traditional long-sleeve warm-up jackets currently on the market are made to be loose fitting. The material hangs down from the arms and could potentially drag across the patient’s skin during the skin prep process, contaminating the surgical site and possibly putting the patient at-risk for infection after surgery.

Dr. Chang and Jennifer Walrich, a senior product manager at Medline, whose team worked with Dr. Chang on the design of PerforMAX scrub, discuss why there is a need in the market for a long-sleeved scrub, how Dr. Chang became involved in its development and partnership with Medline, and what other clinical leaders can learn from her experience in working to bring an idea to reality.

Q: What challenges are presented by existing long-sleeve scrub jackets/scrub warm ups on the market that would necessitate development of an alternative? Dr. Myrna Chang: Let me tell you what the operating room is like. It’s a sterile environment intended to reduce the risk of infecting the patient. The scrubbed personnel wear gowns and protective apparel to reduce the chance of infecting themselves and the patient. But it’s also cold in the OR so the gowns keep them warm. AORN and OSHA guidelines advise non-scrubbed personnel to wear a long-sleeve warm-up jacket in the OR to prevent skin shedding because infection can result if the arms are not covered. It is well known that bacteria from the skin and hair falling out during prep time and while personnel navigate through the OR taking care of patients can increase the risk of infecting the patient.

Another challenge is finding clothing that is comfortable and also looks good. Q: What would you say is “special” about this scrub and why should organizations consider it for use? MC: These new scrubs have a snug-fitting long sleeve sewn directly into the short sleeves of the scrub top. The sleeves are made of a material similar to high-performance athletic apparel that fits snugly around the arms to provide comfort and breathability. Nurses in the OR have to perform for a long time during surgery, so they need material that will hold up over time and that is also comfortable. The sleeves on the PerforMAX scrubs are less likely to come into contact with the patient, which will prevent contamination of the sterile field. This complies with the AORN and OSHA guidelines while also keeping the nurses warm in the OR and providing a fashionable layered look-- something that we never had in the OR. Jennifer Walrich: Also, for the first time in the AORN standards and guidelines, [AORN] indicated all OR scrubs should be laundered at a HLAC-accredited commercial laundry, not taken home to be laundered. Because the scrubs have to be laundered in a commercial laundry, they need to be reversible. One of the major costs for a laundry is labor. So if a scrub comes inside out in the laundry, they’re not going to take the time to put it right-side out before they serve it back to their customer, so it has to be reversible.

Aligning practice with policy to improve patient care 13

Creating a reversible scrub top with an inset long sleeve was a challenge, and it took a great deal of design time and engineering time to figure out how to manufacture it. In addition to its unique tight-fitting sleeve that protects the patient and keeps the caregiver warm, just constructing it from a manufacturing point of view is pretty unique as well. Q: Dr. Chang, what was your involvement in development of the scrub top and how did you work with Medline on it? MC: Both Medline and I had the idea for long-sleeved scrubs independently. I came to Medline with some specific ideas from a user and clinician perspective. Medline and I collaborated extremely well on its design and performance, which is really great. It’s a practical partnership. To bring the clinical perspective and practical perspective to Medline is probably one of the best things I’ve ever done in my career. Medline is our longstanding vendor partner. I feel really fortunate that they’re forward-thinking and open to new ideas. When I introduced this idea, they were very open and excited to work with me. We exchanged ideas back and forth, tested a prototype, trialed the prototype and together we came up with the final product. It was a very gratifying experience. For someone who has never been involved in the clothing industry or developing a new product, they put me at ease and helped me understand products, textiles and things they do on their end. It was a very good learning experience. JW: Myrna came to us with her idea [in June 2011] through our local sales rep. I had talked about a long-sleeve scrub shirt at a sales meeting with our sales reps in April. This particular rep kept that in the back of her mind, and when Myrna had a discussion with her about the idea, that’s what brought the two of us together. Q: Ms. Walrich, how often is Medline approached with ideas? JW: Actually quite frequently. Maybe more than you would expect. We get a lot of ideas from our customers, and we’re always more than willing to entertain them, and in this case, it was perfect timing. Q: How do you think you will feel when the PerforMAX scrub launches at the AORN Annual Congress? MC: More than ecstatic. I was really very proud that I came up with an idea that could help my fellow clinicians solve a problem. To see it come to life is an amazing experience. I can’t believe how easy and enjoyable it was to work with Jennifer

14 The OR Connection

and the rest of her team. They shared the same vision I did on this scrub, and they’re just as excited as I am to share this with nurses everywhere. I never thought I could do something like this. JW: I’m very excited for Myrna, and very excited for Medline. Medline’s foundation is in textiles; we have a really strong history of innovation, especially in scrub apparel, and it’s just nice to be a part of that and create a product that will help our customers. Q: Dr. Chang, people have ideas for new products and solutions all the time but few actually have the opportunity to make their ideas a reality. What do you hope other nurses and clinical leaders learn from your efforts to help launch a scrub that aims to overcome challenges presented by existing products? MC: It’s usually difficult to get ideas off the ground because we clinicians are not sure who to take those ideas to. My message is if I can do it, anybody can. There are people and companies out there in business that are willing to work with clinicians, and Medline is one of those companies. I’m very lucky to partner with Medline. I would encourage people to always use creative thoughts when something is wrong. Don’t stop pursuing your ideas because even the simplest idea can turn into something big that would support clinicians in the OR, such as in this case, and provide patients with the highest quality and safest care. As more and more regulations change, and as more research is done, people will find that there are always things we need to do to improve the way we provide patient care. Nurses or whoever is working on the clinical side should not hesitate to bring forth ideas no matter how simple they are. Reprinted with permission from Becker’s ASC Review.

Yes, They’re Genuine. Only Medline’s Pink Pearl™ gloves combine aloe, nitrile and breast cancer awareness.


Download a QR Code Reader app

2 Launch the QR app 3 Scan this QR Code or visit

©2012 Medline Industries, Inc. Medline is a registered trademark and Pink Pearl is a trademark of Medline Industries, Inc.

Innovation in Patient Warming

Underbody Warming for All Patients and Procedures For protection from unintentional hypothermia in patients undergoing surgery, PerfecTemp is an excellent alternative to forced-air warming systems. While other systems use disposable blankets to force warm air on top of patients, PerfecTemp’s unique surgical table pads offer: Flexible and durable carbon heating element for uniform heating.

• Efficient underbody warming is as effective as forced-air systems for preventing unintentional hypothermia.1 • More accurate patient monitoring • Complete patient access • Silent operation • Reduced staff time • No blowing air • Energy conservation



OR Patient Warming System

References 1. E  gan C, Bernstein E, Reddy D, et al. A randomized comparison of PerfecTemp and forced air warming during open abdominal surgery. Anesth. Analg. 2011; 113(5): 1076-1081. ©2012 Medline Industries, Inc. Medline and PerfecTemp are registered trademarks of Medline Industries, Inc.

TARGETING: Wrong Site Surgery Risks CE Article

{ New Tool Hits the Bull’s-Eye} By Melody F. Dickerson, MSN, RN Project Lead and Master Black Belt, Joint Commission Center for Transforming Healthcare

{ Pre-OP Holding Area Scenario } Patient: Geriatric woman with mild dementia OR Schedule States: Total (left) knee replacement But, the history and physical says that the patient is having the procedure performed on the (right) leg Surgeon Consent Form: Signed by the surgeon reads that the procedure is to be performed on the (right) leg Patient feedback: The patient says she is having her right knee replaced but points to her left leg.

The geriatric patient is a woman with mild dementia, but she is alert and oriented to person, place, and time. No immediate family is present. The nurse’s job is to first have the patient sign the consent, and then to sign the consent as the witness. The patient says she is having her right knee replaced but points to her left leg. This organization prides itself on its 99 percent on-time case start rate and this surgeon in particular hates to run late. The nurse has tried to page the surgeon, but she is in the OR finishing another case and will not have time to come to pre-op before her next case, which is this one. The pre-op charge nurse says that the OR team is coming to

The nurse has two options:

1 Hold the patient until the

paperwork issues are resolved by the surgeon 2 Flag the chart and hope

that it’s taken care of by the next team.

What should the nurse do?

take the patient to the OR.

Aligning practice with policy to improve patient care 17


his is a scenario that no one wants to be in – not the nurse, not the surgeon and certainly not the patient. It’s evident that things started to go wrong long before the patient showed up in the pre-op area. Ideally, we would want to find out exactly when and where the problems first occurred and have solutions that are targeted to address or eliminate them. That’s exactly what the Joint Commission’s Center for Transforming Healthcare’s Targeted Solutions Tool™ (TST) does – and it’s working today to reduce risks for wrong site surgery in Joint Commission accredited hospitals and ambulatory surgical centers. Wrong site, side, procedure or person surgery is a rare event, but it is still too common. It is estimated that wrong site surgery occurs approximately 40 times per week in the United States and it is the most common sentinel event reported to The Joint Commission. These errors can result in devastating injury to patients and families, damage the reputation of the organization, and have a significant emotional impact on the staff who participated in the case. In addition, cases that have gone to trial have resulted in multi-million dollar judgments against the facility and the staff who participated. The causes for wrong site surgery vary but, as in our scenario, most occur due to multiple errors that reach the patient. It is common for these errors to cross through the departments of surgical booking, pre-op/holding and the OR. The Joint

18 The OR Connection

Commission Center for Transforming Healthcare worked with a group of leading hospitals and ambulatory surgery centers to identify the risks of wrong site surgery and to develop solutions targeted to impact these risks. Wrong site surgery is a devastating event, but with the right tools, effective change management, and a multidisciplinary team approach, it can be prevented.

Project Background In 1999, the Institute of Medicine published To Err is Human: Building a Better Health System ( which states: “In health care, building a safer system means designing processes of care to ensure that patients are safe from accidental injury. When agreement has been reached to pursue a course of medical treatment, patients should have the assurance that it will proceed correctly and safely so they have the best chance possible of achieving the desired outcome.” Before that, The Joint Commission and its Sentinel Event program first identified wrong site surgery as a common type of sentinel event in 1996. The Joint Commission has also issued two Sentinel Event Alert newsletters on wrong site surgery—the first published in 1998 and the follow-up in 2001. In 2003, The Joint Commission held its first Wrong Site Surgery Summit, and in 2004, it launched the

Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™ as a National Patient Safety Goal. In 2009, the Joint Commission Center for Transforming Healthcare began work with a group of eight hospitals and ambulatory surgery centers using the tools of Robust Process Improvement™ (RPI) to focus on measuring baseline performance and generating strategies to reduce the risk of wrong site surgery. The Center for Transforming Healthcare was launched in 2009 by The Joint Commission with the sole purpose of using the systematic approach of RPI to analyze specific breakdowns in care, discover their underlying causes, and develop solutions that are targeted to the causes of these complex problems. RPI incorporates tools and concepts from Lean Six Sigma and change management methodologies. In keeping with its objective to transform health care into a high reliability industry, the Joint Commission shares these proven solutions with the more

than 19,000 organizations it accredits and certifies. The focus of this work is on improving the systems and processes used to drive care. The original eight hospitals and ambulatory surgical centers helped to develop a measurement system designed to capture the risks in the surgical processes that could lead to a wrong site surgery in the areas of surgical booking, pre-op/holding and the OR. It is impractical to measure wrong site surgery events since they occur so rarely; instead, the project focused on identifying the risks that could lead to a wrong site, wrong procedure or wrong person surgery. The measurement system involves direct observation and monitoring by trained staff. The following charts show examples of risks for wrong site surgery from each area and a breakdown of how these risks were distributed among the eight participating organizations:

Aligning practice with policy to improve patient care 19

These examples represent how the RPI approach differs from other tools, bundles and checklists currently available to healthcare organizations to help tackle this issue. It’s interesting to note that the risks identified by organization A varied from those identified by organization H. So, for example, if organization A developed a checklist around their risks and processes, it would have worked well. But if organization H implemented the same checklist, it wouldn’t prove to be as successful for them. The key to successfully implementing effective solutions is that they must address the risks that are specific to the organization. For instance, a checklist for organization A may not evaluate the use of the appropriate site marking pen or the use of stickers to mark the site, while organization H struggles with these elements. Through the use of RPI methods, an organization measures its baseline performance to determine which risk factors are most prevalent. The data generated is then analyzed to determine the most common causes of failure or inconsistencies. Many of the organizations involved in the original Wrong Site Surgery project and the piloting uncovered risks they didn’t know they had. For instance, one organization found they were using seven different types of site marks, ranging from an “x,” surgeon’s initials, and a dot. Once risks like this are identified, the organization can develop solutions targeted to impact their specific risks, test the solutions to determine their effectiveness, and then continue to monitor them to ensure that success is sustained.

20 The OR Connection

Results How successful has this approach been? The results of these pilots were impressive, with a reduction of risks identified in all three areas in the surgical processes leading up to the incision.

• Surgical booking experienced a 46 percent

reduction in cases containing risks and a 57 percent decrease in cases containing more than one risk

• Pre-op/holding experienced a 63 percent

reduction in cases containing risks and a 72 percent reduction of cases containing more than one risk

• OR experienced a 51 percent reduction in cases containing risks and a 76 persent reduction of cases containing more than one risk

The following sections illustrate some specific examples of how the solutions have been implemented in the areas of surgical booking, pre-op/holding and OR.

Surgical Booking The preparation of the OR schedule can occur weeks in advance of the surgery and it can be difficult to fathom that an error occurring this far from the time the patient actually shows up in the operating room isn’t caught before harming the patient. In 2009, the Pennsylvania Patient Safety Authority ( ADVISORIES/AdvisoryLibrary/2009/Sep6(3)/documents/104.pdf ) identified incorrect OR schedules as a contributing factor to wrong site surgery. Most OR staff use the OR schedule as the roadmap for room set up; this set up creates a powerful visual cue to the entire team as to the laterality of the case and the procedure being performed. The audit tools developed to measure this part of the surgical process specifically evaluate the receipt of forms to the organization performing the surgery and the booking form itself. For the receipt of forms, the top three areas of weakness identified by the project teams were: verbal ordering of procedures without written documentation; multiple booking forms received for the same surgical case; and cases scheduled within 48 hours of the surgery date. While the findings weren’t surprising to the individuals who usually prepared the surgical schedule, it was surprising to the OR leadership, particularly the frequency of verbal scheduling without the support of written communication.

when used to identify laterality of the surgical site. For ambulatory surgical centers, conflicts between the procedural coding and written description of the procedure were frequently identified as risks and required follow up with the ordering physician’s office. The solutions for these also varied, but all involved engaging the physician’s office staff. Some solutions included sharing information needed to make the surgical booking process as easy as possible for the office staff. Other identified solutions included the development of a resource manual containing: a list of unapproved abbreviations; hard copies of the ordering form and the order change form; frequently used telephone and fax numbers; and frequently asked questions. Most facilities began a series of lunch meetings with the offices that frequently book surgical cases. The purpose of these meetings was to engage these practices in collaborative conversations about improving the process for both parties and, most importantly, ensuring that cases are booked accurately. Other solutions, while seemingly simple, required a significant commitment by the organization performing the surgery. These solutions included implementing a single booking fax line where all documents pertaining to surgical cases could be faxed; or implementing electronic scheduling, even for practices that are not directly affiliated with their facility. The result of these solutions and others resulted in a 46 percent reduction in defective cases in surgical booking.

While errors on the booking form varied as well, the most common errors related to the use of unapproved abbreviations, particularly

Aligning practice with policy to improve patient care 21

Pre-op/Holding In the pre-op/holding areas, paperwork issues continue to be a problem, with documents critical to the patient verification process (e.g., signed surgical consent, history and physical, and operating room schedule) being incorrect, incomplete or missing. Exacerbating this issue is the metric on which many hospitals and ambulatory surgical centers pride themselves -- on-time OR case start rates. Many staff said that they felt rushed to get the patient ready for surgery because they were searching for or coordinating last minute revisions to primary documents. It was also common for staff to be uncomfortable stopping the patient flow to the OR due to paperwork concerns. Staff stated they would flag the documents in question, relying on the next caregiver to make corrections. Other risks identified included the identification of inadequacies in the patient verification process. For instance, it was common to find the surgeon not using a second patient identifier or referencing the procedure site and side using one of the primary documents (e.g., history and physical or signed surgical consent). When asked why, many stated that they felt the patient might be offended if asked for a second patient identifier, or they assumed that another team member was verifying the procedure site and side using the primary documents. The solutions to these problems were not simple; they involved strong leadership support to making change and holding staff accountable. The solutions required that the primary documents, specifically the history and physical and the signed surgical consent, be available the day before surgery. If the case was scheduled as a first case, it would be bumped to a later time so that the paperwork could be pulled and the patient information properly verified on the day of surgery. This solution required that the organization performing the surgery have a well established surgical booking process, and a mechanism for verifying the presence of the primary documents and for reporting any missing documentation back to the ordering practice within the 48 hours preceding the surgery date. Another key in changing behaviors of the surgical team was the use of “just in time” coaching – coaches who actively intervene when they observe noncompliance in order to understand an organization’s contributing factors, and to coach healthcare workers on proper com-

pliance. These coaches helped address concerns about patient verification and patient perceptions. As a result, a new practice is to inform patients upon arrival on the day of surgery that they will be asked by all team members to recite their name, second patient identifier, procedure, site and side. In addition to paperwork concerns, many of the pilot organizations also audited regional blocks performed by anesthesia in the pre-op areas. The group found many regional blocks were being performed without a formal timeout process or without a site mark specific to the block. These omissions were identified as risks for wrong side or site surgeries in 2009 by the Pennsylvania Patient Safety Authority. The solutions involve engaging anesthesia providers to design a time out process which includes a nurse in the pre-op area. The time out process ensures appropriate patient verification involving the alert patient to ensure the correct procedure, patient and laterality. In addition, the patient is engaged in a formal site marking process. The site mark consists of an unambiguous mark that is specific to anesthesia, such as the physician’s initials with an A with a circle around it ( A ) to differentiate the mark from the surgeon’s mark. The impact of the solutions implemented in the pre-op/holding areas resulted in a 63 percent reduction in the rate of cases containing risks and a 72 percent reduction of cases containing more than one risk.

Operating Room In the operating room, all of the participating organizations found that team attention during the time out process was lacking. It was not uncommon to find staff continuing to work and set up the OR suite while the time out was being performed. There were many causes for this inattention, including the timing of the time out itself. It was discovered that if the time out is performed before the patient is prepped, staff will continue to set up the room and find it difficult to stop what they are doing and to participate in the time out. In 2009, the Pennsylvania Patient Safety Authority identified time out processes that were performed before the patient was prepped and draped as a risk for wrong side or site surgery. In addition, staff inattention was found to be more of a problem if the entire team did not participate fully in the time out process. It was common to find a single circulating nurse Continued in Page 24

22 The OR Connection

Despite best efforts, wrong site surgeries occur. We’d like for that not to happen to your patients, your staff and your organization. Organizations that are accredited by The Joint Commission have free access to the Targeted Solutions Tool™ (TST) that can help them discover practical and field tested ways to eliminate the causes of wrong site surgeries. The TST provides an interactive web-based process that helps organizations identify, measure and decrease risks in key surgical processes.


By utilizing the TST, organizations can evaluate risk in • Scheduling • Pre-operative care • Operating room area The TST, which was developed by the Joint Commission Center for Transforming Healthcare, is the platform for several key health care initiatives. To help address the wrong site surgery challenge, the Center collaborated with several hospitals and ambulatory surgical centers to develop the solutions by utilizing concepts and methods from Lean Six Sigma and other change management tools. The results so far……….. Area Scheduling area Pre-op OR

Reduced Risk 46% 63% 51%

For more information and for the opportunity for a guided tour of the tool for your organization, contact

A key factor to the success of any process improvement project.... Is active engagement of key stakeholders and the use of change management strategies.

responsible for reciting the key elements from the signed surgical consent while all the other team members participated passively. The solution is to create a role-based time out process where every team member not only has the opportunity to participate, but is expected to participate. The data collected during the baseline period will help the organization identify which role is best suited to initiate the time out. The TST provides scripts that outline a time out process that can be tailored to the organization. For instance, one organization’s time out process includes the Universal Protocol and may combine multiple elements, such as blood products, implants or radiographic images. Another organization may choose to pull out these elements and perform them during a briefing process that occurs before the prep and drape. This briefing process would include the Universal Protocol and be completely separate from -- but in addition to -- the time out, and it would occur after the prep and drape. Either approach is acceptable. The key to success is staff buy-in to the process and the sense that the multidisciplinary team is responsible for keeping patients safe, rather than the surgeon alone. The results of these solutions and others resulted in a 51 percent reduction in the rate of cases in the operating room containing risks and a 76 percent reduction of cases containing more than one risk.

Change Management A key factor to the success of any process improvement project -- particularly one that requires such a diverse group of individuals as those found in most surgical services -- is active engagement of key stakeholders and the use of change management strategies. One of the first exercises that the Center’s project teams are asked to engage in is an evaluation of the stakeholders in the process. For the Wrong Site Surgery project, anyone directly affected by any changes made to the processes that lead up to the surgical incision should be engaged in the project. Stakeholders can be groups or individuals; the goal is to determine early on if the project has the support needed for success. If not, strategies need to be developed early in the process to help bridge the gap between where the group or individual is in

24 The OR Connection

supporting the effort and where they need to be. For example, the project may lack the support of anesthesiologists because they are wary of any project that might impact the way that they perform the time out for regional blocks. The project team may decide that the best way to engage this group is to ask the section head to attend team meetings and work with the team to refine processes, particularly those that directly impact anesthesiologists. Organizations are encouraged to weave change management strategies throughout the improvement process to optimize success -- even after the project has been completed and solutions have been successfully implemented. It is important to continue to give staff feedback on their performance, validating that the hard work they have done to make change was worth the effort and to ensure that improvements are sustained. A great way to provide this feedback is to continue with the auditing process, sharing data during staff meetings, posting results in an area frequented by staff, and celebrating improvement and sustainment. The pilot organizations have found that this data can be easily captured with just one audit being performed per day in each area.

How the Solutions are Spread The Center for Transforming Healthcare has taken the information learned through the original participating organizations and the pilot organizations and made them available via the Targeted Solutions Tool™ (TST) for Wrong Site Surgery. The TST for Wrong Site Surgery is explicitly designed for hospitals and ambulatory surgical centers with the goal of spreading these results throughout the country. The TST is now available free of charge to Joint Commission accredited and certified programs. The TST is a self paced, web-based application that provides a six-step process that guides an organization through the following steps:

• stakeholder analysis • identification and training of data collectors • data collection and entry • automated data analysis, provided in a presentation ready format • solutions targeted to the organization’s data results • plans and tools for sustaining improvements

For more information about the Wrong Site Surgery project or the Targeted Solutions Tool for Wrong Site Surgery, visit the Center for Transforming Healthcare website at or email


Targeting Wrong Site Surgery Risks: New Tool Hits the Bull’s-Eye True/False

1. A retained foreign object after surgery is a common sentinel event reported to The Joint Commission. T F

8. Regarding surgical booking, which of the following was one of the top three areas of weakness identified by the project teams?

2. The key to successfully implementing effective solutions is that they must address the risks that are specific to the organization. T F

a. Cases scheduled within 48 hours of the surgery date

3. In 2009, the Pennsylvania Patient Safety Authority identified incorrect OR schedules as a contributing factor to wrong site surgery. T F

c. No patient insurance information on file

4. Implementing electronic scheduling was found to be one solution for avoiding errors in surgical booking. T F 5. Organizations are encouraged to weave change management strategies throughout the improvement process to optimize success. T F

b. Incorrect documentation of patient medications d. None of the above 9. Which of the following “Validated Root Causes for Risk of Wrong Site Surgery” were experienced by all eight pilot hospitals? a. Unapproved abbreviations, cross-outs, and illegible handwriting used on the booking form b. Time Out performed without full participation c. Both a and b

Multiple Choice

d. All of the above

6. The Joint Commission first identified wrong site surgery as a common type of sentinel event in:

10. What did all of the participating organizations observe regarding the time out process in the OR?

a. 1989

a. Surgical teams often forgot to perform a time out

b. 1996 c. 2002

b. Surgical teams were too rushed to perform a time out

d. 2007

c. Team attention was lacking during the time out

7. Which three areas does The Joint Commission’s wrong site surgery measurement system encompass?

d. None of the above

a. Surgical booking, pre-op/holding, the OR b. Pre-op/holding, the OR, post-op/recovery c. Surgical booking, surgical time out, post-op/recovery d. None of the above Course is approved for continuing education by the Florida Board of Nursing and the California Board of Registered Nursing. Visit and login or create an account. Choose your course to take the test and receive 1 FREE CE credit.

Aligning practice with policy to improve patient care 25





By Kathleen Bartholomew, RN, MN

You are part of a team doing a tracheal resection when one surgeon drops out and performs a bronchoscope exam, contaminating the sterile field. He doesn’t want to bother with re-draping because “the unsterile endotracheal tube and breathing circuit will be attached rendering the entire setup clean anyway.” It’s not the first time a surgeon you have worked with has switched from sterile to aseptic technique unexpectedly during an operation. And after all, his request is logical. But still, the whole experience is unsettling. Your job is to keep the field sterile, and years of training and expertise and vigilance feel suddenly challenged. Is it mind vs. emotions ... personal vs. professional? So you say something, and before long you are perceived as a “troublemaker.” Other little events occur, and an internal dilemma builds. You insisted just last week that the sponge and needle count be performed at change of shift per policy,

26 The OR Connection

and the circulator rolled her eyes. To speak up, or remain silent? Welcome to “The Gray Zone.” “The Gray Zone” is the psychological “no-man’s” land between black and white. It’s those moments when we question ourselves and what is truly the right thing to do. They are all those situations that weren’t covered by your teachers in school …or are not in the policy book … or are not addressed effectively by management. Hospitals today are filled with Gray Zones, which have become an integral part of the healthcare culture. This is one of the major reasons that 22 patients die an hour from preventable errors. Not so in other industries … Nuclear power operators, submarine, high-rise construction and aviation are all high-risk professions that have learned from experience that you don’t ever deviate from the plan

For every quarter of TEAM training, the mortality rate decreased 0.5 per 1000 procedure deaths

or standard procedures during critical phases. Ambiguity undermines self-esteem, decreases morale, and creates an unjustified level of risk. Indeed, procedures are primarily for the purpose of guiding humans through these adrenalcharged times when our amygdala (the structure within the brain that appears to be at the very center of most events associated with fear) is hijacked because they have discovered—after many deaths— that human beings can’t think straight when they are upset. Furthermore, when you introduce a little deviation … then over time you permit a little more … and a little more. I was called to an operating room where the anesthesiologist accidentally drew up 10cc’s of epinephrine instead of the intended toradol. The patient coded and was revived after some difficulty. The anesthesiologist did not catch Continued in Page 29

Aligning practice with policy to improve patient care 27

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the error himself and it was discovered that he was on his cell phone talking to his stock broker while administering the medicine to an 18-year-old knee surgery patient. It was no surprise to discover that everyone in the room had a cell phone in their pocket. No doubt this started when a member of the team was worried about a sick child, or waiting to hear if they sold their house. That’s how allowing a phone into the room over several years in this particular O.R. became “normalized” – just like the Challenger explosion – or allowing minor deviations from sterile technique. In sociology it’s called “creeping normalcy,” because when something creeps slow enough over a long period of time, no one can see it advancing. Over time, we get sloppy without realizing it.

It’s like changing the rules of the game in the fourth quarter. Great O.R. teams call these covert and overt behaviors out – after the operation during the debrief.

I haven’t met anyone yet who doesn’t want to do the right thing. But people’s ideas of what is “right” sometimes conflict. Is it ok to switch from sterile to aseptic technique during an operation? Only if this switch was planned before the operation began. The time to discuss a change– any change– is never in the middle of a procedure.

A debrief is absolutely critical and can be done while changing out the room. What worked well? What needs improvement? Did the operation go exactly as planned? Were all procedures followed? If not, what can we resolve now – and what needs to be tabled for later? Great teams are always looking for an opportunity to do better.

Collegial teams don’t disagree (even overtly) during an operation. If you need to discuss something pertinent to the procedure, then wait until the surgery is over. In aviation it’s called the “sterile cockpit.” Only conversation about the task at hand is permitted below 10,000 feet because that is a critical phase of flight. In the last U.S. airplane crash they broke this rule. The conversation distracted them, they lost control of the plane in Buffalo and everyone died. (Same principle as “don’t text and drive.”) The acceptable methodology in handling a disagreement below 10,000 feet is to say, “We’ll talk about this on the ground.” If the patient is in the operating room, then you are below 10,000 feet.

Sounds clear enough – but that’s not reality in many operating rooms today. What if the surgeon is getting upset and over-rides the “we’ll discuss this later” script? The welfare of the patient is always paramount. There may be times when you need to acquiesce simply to calm the surgeon and create peace. Then, it is absolutely incumbent on the entire team to debrief – or agree on a time to debrief later if emotions are still high – or to not participate in the same operation again until the issue has been resolved to the team’s satisfaction.

From the moment the patient enters the operating room to the time he or she leaves is always a critical phase – but much more stressful. Humans under stress frequently say or send off signals that are unintentional, yet harm or distract the team. Research shows that simply witnessing rude behavior significantly impairs our ability to perform cognitive tasks. In other words, it’s not ok for anyone to ever upset someone else – even unintentionally— by sending off negative vibes or suddenly altering the procedure.

For every increase in degree of briefing and debriefing mortality rate was reduced by 0.6 per 1000 procedures

Teams that debrief have made tremendous strides toward changing the culture of the operating room, which has been traditionally a hierarchy. Historically, debriefing has not been easy because it is perceived as a threat to the surgeon’s autonomy and power — as evidenced by our everyday casual conversations. The surgeon walks rapidly down the hall saying, “Where’s my patient?” In the next room the scrub is instructing a new nurse: “Some people say the handles of the fluid pitchers need to be inside the warmer basin. I like mine hanging over the edge.”

Aligning practice with policy to improve patient care 29

The use of the words “my,” “mine” and “I” are frequently heard throughout today’s operating rooms; and no one thinks much of them. But they are a clear indication of the old hierarchical culture. Great teams don’t use possessive pronouns. In a collegial interactive team, people would say “our” patient and this is the way “we” do it. Preference cards would be virtually nonexistent, as surgeons would have used evidence-based practice to uniformly agree on the tools and techniques for each particular surgery. There would be no need for multiple preference cards – just one card per surgery. I’ll admit this is not the realty of most operating rooms. It’s not even the way they do it on television. So how do you get there? How do you change from a traditionally hierarchical culture to a collegial team? By your words – by speaking up. Words change a culture. Silence is unfortunately the norm, however, because the first person to unveil the gray zone…or request a debrief … or say “We’ll plan the switch to aseptic next time”… or “Don’t use your cell phone” puts himself in an extremely vulnerable position by behaving differently than the group. Protect them. Watch out for these people because they are truly courageous leaders. Follow them. Know that your voice is more powerful than you ever imagined. Join them, and eliminate the Gray Zone. Patient safety and adherence to best practice is black or white. We either do what we know will keep our patients safe – or we don’t. Reference: “Association Between Medical Team Training and Patient Mortality” Julia Neily; Peter D. Mills; Yinong Young-Xu; et al. JAMA 2010;304. Available at: http://jama.ama-assn. org/content/304/15/1693.full. Accessed February 7, 2012.

30 The OR Connection

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Communication and Teamwork Set Them Apart 32 The OR Connection

Sue MacInnes recently had the opportunity to meet with Dr. Bill Rupp, CEO of the Mayo Clinic in Jacksonville, Florida. Here is some of the conversation that resulted from that meeting as they discussed the culture of safety at Mayo ‌ followed by a guided tour of the hospital to see and feel communication and teamwork in action ‌

Aligning practice with policy to improve patient care 33

Sue MacInnes: Dr. Rupp, is there anything you’d like to say to The OR Connection readers? Dr. Rupp: Let me start with a couple thoughts… Healthcare professionals have historically been taught to work hard and study hard. And the culture is if you work hard enough and study hard enough you won’t make a mistake. But it doesn’t always happen that way. I don’t know anyone who comes to work in the morning and says, “I think I’m going to screw up today and hurt somebody.” But it happens, because we are human beings and we have systems that are incredibly complex. We’ve created a culture of “work hard study hard” so that the conclusion is if you do make a mistake, you obviously didn’t work hard enough. SM: And you end up blaming yourself. Dr. Rupp: Yes. You blame yourself. The other thing that is a real challenge in our culture is communication. If you don’t communicate against the gradient a patient might die. And then you have high gradience in healthcare with doctors, nurses and others up and down the line. So, even in organizations as wonderful as Mayo, where our strength is that we are physician led, and our potential Achilles heel is that we are physician led. So challenging against the gradient is a real issue. We are working hard to teach people to do that by getting them more comfortable with sharing information. It is a multi-year journey to get a culture to be that way. SM: Do you think that Mayo is different because you are physician led? Dr. Rupp: I think we are different because we are all on the same team. We don’t have physician groups working for their own economic incentives that could potentially hurt the organization. One of the challenges in healthcare systems in the U.S. is when physicians are competing against hospitals. And the hospital that the physician works for is often the physician’s greatest competitor. So, they are not on the same team. I hope that healthcare reform brings us all together collaboratively, so that we’re all on one team.

34 The OR Connection

SM: Where are the biggest Mayo sites and how does your facility fit into the rest of the Mayo system? Dr. Rupp: The three big sites are Rochester, Minn., Arizona and Florida. We are called three-shield academic centers: research, education and practice—with practice being our most important component. And we have a fair amount of basic scientific research on this campus and the other two campuses. We all have residents in education programs. Our push over the last couple of years has been to be one Mayo Clinic. We want to be standardized across our organization, so that if you come to Florida with a TIA, you’re going to get the exact same treatment and work-up as you would in Rochester or Arizona. We already do it in a number of areas. If you need a kidney or liver transplant, you get an identical work-up at all three sites. We have the same kind of surgery, and we have the same kind of post-op follow up in all three. In fact, we’re working on getting people listed to work at all three sites. SM: Do the three sites ever get together? Dr. Rupp: Yes. We have what we call “councils,” where our transplant people from each site get together and standardize things.

SM: But it must be hard. Don’t you have different cultures in each of the sites? Dr. Rupp: Yes, it’s very hard. But fundamentally it’s still a Mayo culture. So we’re very similar to start with. We go to great lengths to share information and procedures. SM: How do we engage more healthcare facilities to get “top-down” leadership to be more transparent, especially understanding that many people might choose not to do that because it exposes too much? Dr. Rupp: First, when we are transparent, it makes the staff believe in us more because they know we’re not hiding stuff. Second, by the very process, we all admit that we are human and most of the time when we have mistakes; it’s the system that’s the problem. There is growing evidence that transparency leads to fewer losses – not more. The other thing that you will see with our quality boards is that we are transparent by making the boards available to patients and families, as well as staff. When numbers are not going right, the staff is all over it because everybody sees it. SM: When did you start putting these numbers out? Dr. Rupp: Ten to 15 years ago. The idea came out of the Institute for Healthcare Improvement – like posting in ICU the number of days since the last ventilator problem.

SM: How long does it take for before the staff becomes OK with the transparency? Dr. Rupp: It takes a little time. In one of our major meeting rooms here we have quality boards on the wall with data on infection, financials and service. We put it up on a big poster board because that room is the most common meeting room in the facility and everybody that goes in there says, “Oh, so that’s what they are watching.” We had visitors from other parts of the system who were initially shocked that we had that data so “publicly” displayed, and yet now it appears that other places are doing it as well. SM: Were you the first place to put up these boards? Dr. Rupp: We were certainly one of the early places. SM: Do numbers make you feel uncomfortable? Dr. Rupp: Yes and no. They just are. They increase the quality of the data and can increase the quality of care. In 2008 we said let’s get rid of ventilator-associated pneumonia. And typical of a very good medical center, I was told that we probably couldn’t do that because we have some sick patients. Well, in 2008 we had 14 cases, in 2009 we had seven, and in 2010 we had three. Last year we had one. So, we’ll get there. In 2008 we had 36 central line infections, in 2009 we had 18, in 2010 we had 10, last year we had six. So, by just putting the numbers out there we are affecting the quality of care.

Aligning practice with policy to improve patient care 35

SM: I bet you are proud of that. Dr. Rupp: Yes, I’m very proud of our staff, and yet our goal is to get our rates to zero. SM: So, you care about the number of individual incidents? Dr. Rupp: The number of individual patients is important. If we have the lowest infection rate in the world and I am that one patient... SM: I agree. Percentages are meaningless because the percentage could still mean a significant number of people. Dr. Rupp: More than that. When you’re talking real numbers, you’re talking real people. At my previous position I shared patient names with board members. It showed that the numbers are people. And suddenly to the lay board members it became real – because they knew “Mary Smith” or “Paul Johnson.” SM: Can you tell me a little about the patient/doctor relationship at Mayo? Dr. Rupp: One of our ENT surgeons was in the operating room working on a patient with a basal skull lesion and he was getting near the end of the surgery when he got a call from the ICU. They told him a patient he had operated on two days before was bleeding. They asked him to come and look at it. And it became obvious very quickly that the patient was going to have to go back to the OR right away. So, the ENT surgeon called one of

the plastic surgeons in a very busy clinic and asked, “Can you get down here and finish this case for me, because I have to take care of another patient.” The plastic surgeon came down and finished the case while the ENT surgeon fixed the bleed on the other patient. When the ENT surgeon was done with the bleeding patient, he came back and kept the surgery line going. Rarely would a surgeon walk in on a patient that he has never seen before, like the plastic surgeon did, and finish the case. Mayo’s focus is on meeting the needs of the patient. SM: It all stems from the belief that the patient is number one. You have to do everything for the patient. Dr. Rupp: Another thing you’ll notice here is that our patient areas are very nice. Our administrative and doctor areas are also nice, but not like the patient area. We put the dollars into the patient area. SM: Tell me about the OR. Dr. Rupp: We had a challenge. We had a system that allowed us to do any case at any time, and it made life very unpredictable for our OR nurses. They might come in one day and get sent home early because there weren’t that many cases. And then the next day they would come in and be here until 10 or 11 pm. It is incredibly disruptive for somebody trying to run a family, pick up kids, etc. So, we changed to a system that is much more orderly with scheduling up to 24 hours in advance. We have rooms that run from 7 am till 5 pm, and we guarantee that those rooms will Continued in Page 39

36 The OR Connection

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References: 1. Occupational Safety and Health Standards, Toxic and Hazardous Substances, Bloodborne pathogens. Regulations (Standards - 29 CFR). Available at: http:// id=10051#1910.1030(d)(2)(i). Accessed October 13, 2010. ©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Safety-Splash and S.T.O.P are trademarks of Medline Industries, Inc.

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be finished by 5 pm. We have one or two rooms that can run longer for emergencies, transplants, and the other things. But it’s confined to a small group of people who know they are on call for that evening and that they are at risk for running longer. So, we plan it that way. This has dramatically cut down on turnover. It’s made us a popular place to work. We now have a waiting list for people who want to work in our ORs. SM: How many OR suites do you have? Dr. Rupp: 18. SM: How many surgeries do you do? Dr. Rupp: Approximately 12,400 surgical procedures per year. Sue: And what type of surgeries do you specialize in? Dr. Rupp: Very complex patients. We are a major transplant facility. We do about 400 solid organ transplants a year. We do very complex cardiology procedures. As well as complex valves with very sick patients. If you think of health care as a pyramid, we do the very top of the pyramid. We do almost all the intra-cerebral bleeds for 100 miles around. Because we have people who can fish those clots out or coil the aneurysm, even when it is the most difficult thing. We have data that shows that we get the sickest and most complex patients in all of Florida. SM: Describe some of the things that you’ve personally done to improve performance. Dr. Rupp: It’s my continuing role to focus on quality, safety and service. If you ask our staff what I’m about, they will tell you quality, safety and service. Now, I don’t ignore a financial bottom line. I am responsible and accountable for producing a bottom line. But with a professional staff, that bottom line comes if we focus on quality, safety and service ... The dollars just follow. SM: I’ve heard you referred to as the “barrier buster.” How did you get that name? Dr. Rupp: I think that my major job is to take down barriers. I keep telling our people that if you want me to come and fix your problem that’s pretty scary because I do not know anything about what you do on the frontline. So if you want me to fix your problem from the desk you are in real trouble. Now you work in it all the time and know about it. My job is for you to say that you have a problem or a barrier that is keeping you from making it better for patients or whomever else. Fine. I will help you get rid of that barrier but I’m not going to get lost in the details.

SM: So, you help them break down barriers that have been in place forever? Dr. Rupp: Yes. So much of what we do was done for a good reason sometime back. And yet things have changed and we’ve got all these things still in place that we’ve always done. To me, the most frightening words in health care are “We’ve always done it that way.” SM: How can we improve the physician/nurse relationship? Dr. Rupp: One of the biggest ways is going to be simulation. SM: Why do you say that? Dr. Rupp: I think simulation will revolutionize medical education. The ability to work in a simulation center is going to change much of what we do. SM: Do you have a simulation center? Dr. Rupp: Yes, every one of the three major Mayo sites has one. For example, the ability for a team to practice putting in a central line, not just the doctor, but also the nurse who that doctor is going to be working with, or the tech, or whoever it is. We are doing some interesting exercises right now on the deteriorating patient: the one who is starting to get real sick. And what does the team do with that? The ability to go in and do it in the simulation center, then later sit back with everybody and watch the video that we made. You can actually watch what worked well, what did not work well, what communication was good, what communication wasn’t good, and evaluate what you learned, and then do it all over again.

Aligning practice with policy to improve patient care 39

SM: How do you get the physician to do that – to take the time to do that? Dr. Rupp: That is part of our job as physicians. This is what is required at Mayo. If you are going to put in central lines in this institution, you have to go through the simulation center.

SM: Are you serious? Dr. Rupp: I’ve seen incidents in simulations where after resuscitation nurses don’t want to leave the “patient.” I think to myself, you know, it’s a dummy, but they still do not want to leave. People get incredibly involved in it.

SM: Do you make the simulation center a requirement? For physicians? Dr. Rupp: Yes.

SM: How long have you had the simulation center? Dr. Rupp: Mayo has had one in Rochester for about five or six years. Arizona got theirs three years ago. Our temporary one went up a year ago, and we’ve put 3,000 people through it so far.

SM: Is that normal? Dr. Rupp: It is here! It’s a growing segment in the things we do. If we have an issue, we want to use simulation. You don’t get to say no. We simulate as much as we can. We have even had a housekeeping crew say, “We have a way of cleaning a room that might be faster and safer and we’d like to try it.” Great! Go to the simulation center. SM: Do they act it out, work it through, and then demonstrate their findings? Dr. Rupp: Yes. And sometimes even more than that. What happens in the simulation center is that we have mannequins and dummies. Our staff gets incredibly involved with these mannequins. The mannequins do everything. They talk, and we even have one that will vomit on you.

40 The OR Connection

SM: So this is a pretty new thing? Dr. Rupp: Yes. SM: Have you seen a difference in the relationships? Dr. Rupp: Yes. It helps the relationships. There’s also a focus on the fact that we are not perfect at teamwork, but we try. Somebody asked me the other day, who are your superstars? And I said, “Superstars at Mayo do not do very well. We don’t have superstars. We have superstar teams.” In this day and age with medicine and its complexity a superstar cannot survive here alone. A superstar needs a team around him or her to provide great care. So the focus is on teamwork. We actually have courses on how to have conversations, especially with somebody who may be a little difficult. The book is called Crucial Conversations.

Crucial Conversations Tools for Talking When Stakes Are High by Kerry Patterson, Joseph Grenny, Ron McMillan & Al Switzler

If you feel stuck — in a relationship, in your career, at home — chances are a crucial conversation is keeping you there. The summary of this New York Times bestseller will help you handle crucial conversations — conversations that occur when the stakes are high, emotions run strong, and opinions vary. With crucial conversations skills, you’ll be able to: prepare for high-stakes situations with a proven technique; transform anger and hurt feelings into powerful dialogue; make it safe to talk about almost anything; be persuasive, not abrasive; improve nearly every professional and personal relationship; and yield major professional improvements in areas like productivity, quality, safety, diversity, and change management.

SM: I’ll have to read it when I get home. Dr. Rupp: Oh, it’s great. It teaches the skills for how to interact with difficult subjects. We teach doctors how to deliver bad news. How you handle an angry patient. It teaches skills that aren’t normally taught in our professional training. Dr. Rupp: Now, let’s take a walk. I’d like to show you some of our campus. SM: Wow. Is this a new building? I really like the look of it. I love the workspaces outside the rooms. Dr. Rupp: And there’s a workstation in each room as well. Here’s one of our quality boards. SM: It’s out for everybody to see. Wow! They have not had a “Fall” since November. Dr. Rupp: In this unit. Dr. Rupp: We belong to a patient satisfaction group called PRC. It includes more than 300 hospitals—mostly academic medical centers. We were the number one hospital in patient satisfaction in 2009 and 2010. We don’t have the 2011 results yet. So, among those 300 or so hospitals, we had the highest patient satisfaction of anyone.

SM: Wow! I love how you have this published like this. I love the nurse stations. That’s really good. Dr. Rupp: You see that every room on the floor is identical. From the patient area, to the family area, to the staff area. SM: They are good spaces. Dr. Rupp: Yes. Especially, the staff area and their workstations. SM: And the workstations are not on top of the patients. The rooms are spacious. Nice. This was well thought out. Dr. Rupp: The hallways are pretty wide too. Over here is the cleaning supplies room. Every supply room is the same. Everything is in the same place in every supply room. Nurses can float floor to floor, and the arrangement is all the same. They did this as a “lean” project. People used to come in here and spend 20 minutes looking for something, and when they found it, they did not bother to charge for it. Now they come in, get what they want, they charge for it, and go. SM: You’ve done so much work. Dr. Rupp: We have great people here.

Aligning practice with policy to improve patient care 41

View from Dr Rupp’s office. The best views are reserved for patient rooms.

Dr. Rupp: As you can see, our hospital is connected to our clinic buildings. Everything is together. So, for example, if you’re in your clinic office and the hospital calls and says, “Mr. Smith is not looking good,” you can literally be at the patient’s bedside in one to two minutes, or they’ll say, “Oh, no he’s doing fine,” and you can go back to your office. Dr. Rupp: This entire facility is literally built on a 100-year plan. So, everything can go up and flip over. The hospital is six stories. It can go up 10 more. This building can go up six more stories, and then it can flip over and go up again. SM: So, you build it for the future. That’s really smart. Dr. Rupp: This is all about value, you know. The value goes into the patient. And it’s all these little kinds of things that demonstrate that. SM: What have you learned about how to resonate with the people who can make a difference here, whether it’s the board or the staff? Dr. Rupp: Staff and healthcare professionals get turned on by making things better for their patients, by delivering better care. They don’t get turned on by saving money or making mon-

42 The OR Connection

ey for the organization. In fact, they are naturally suspicious that you do that at the cost of hurting somebody or not giving somebody everything that we could. They get very turned on by making the quality better. And then over time, we get to teach that when you make the quality better you also save a lot of money ... and with that money we can then turn around and fund education. We have 169 residents right now. We funded about 110 of them this year. And we put $800 million into basic science research last year. SM: I’d like to thank you again for being so generous with your time. It has been very enlightening. Dr. Rupp: You are more than welcome. Come back any time.


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Reference 1 Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reduces urinary catheterization in hospitalized patients. Jt Comm J Quality Patient Saf. 2005; 31(8): 455-462 2 Patient Safety Quality Measures for the Surgical Care Improvement Project (SCIP). Health Services Advisory Group. Available at: Accessed December 7, 2010. 3 Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009. Centers for Disease Control and Prevention. Available at: Accessed December 7, 2010. ©2012 Medline Industries, Inc. Medline is a registered trademark and InserTag is a trademark of Medline Industries, Inc.


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Correction Patient Safety Mystery Message Answer, Volume 6, Issue 2

In the puzzle featured in the last issue of The OR Connection, we missed mentioning that the clinician in the photos should have been wearing sterile gloves. Thank you to reader Mike Koball, RN, BSN, Clinical Manager of Surgical Services at Venice Regional Medical Center, for discovering our oversight.

Aligning practice with policy to improve patient care 45

PATIENT SAFETY NEWS PATIENT SAFETY NEWS C. diff Infection Rates at Historical High New CDC report offers facts and solutions While most types of healthcare-associated infections are declining, C. difficile infections are at an all-time high. Although 94 percent of C. difficile infections occur in healthcare settings, few of them are due to hospital exposure, according to a new report from the Centers for Disease Control and Prevention. About 25 percent of C. difficile infections first present symptoms in hospital patients; 75 percent first show in nursing home patients or in people recently cared for in doctors’ offices and clinics. The report highlights three programs showing early success in reducing C. difficile infection rates in hospitals. The 71 hospitals participating in the programs in Illinois, Massachusetts and New York decreased C. difficile infections by 20 percent in less than two years by following infection control recommendations. To download a copy of the report, go to: mmwr/pdf/wk/mm61e0306.pdf. C. difficile causes diarrhea linked to 14,000 American deaths each year. Those most at risk are older adults who take antibiotics and also receive medical care. When a person takes antibiotics, resident bactheria that protect against infection are destroyed for several months. During this time, patients can get sick from C. difficile picked up from contaminated surfaces or spread from a healthcare provider’s hands. C. difficile causes many Americans to become sick or die. • Deaths related to C. difficile increased 400% between 2000 and 2007, due in part to a stronger germ strain. • Most C. difficile infections are connected with receiving medical care. • Almost half of infections occur in people younger than 65, but more than 90 percent of deaths occur in people 65 and older. • Infection risk generally increases with age; children are at lower risk.

46 The OR Connection

C. difficile moves with patients from one healthcare facility to another, infecting other patients. • Half of all hospitalized patients with C. difficile infections have the infection when admitted and may spread it within the facility. • The most dangerous source of spread to others is patients with diarrhea. • Unnecessary antibiotic use in patients at one facility may increase the spread of C. difficile in another facility when patients transfer. • When a patient transfers from one facility to another, healthcare providers are not always told that the patient has or recently had a C. difficile infection, so they may not take the right precautions to prevent spread. C. difficile infections can be prevented. • Early results from hospital prevention projects show 20 percent fewer C. difficile infections in less than two years with infection prevention and control measures. • C. difficile infection rates decreased by more than half in hospitals in England in three years by using infection control recommendations and more careful antibiotic use.

Source: Centers for Disease Control and Prevention Available at:

Lean tools and concepts

reduce waste, improve efficiency A Magnet™ organization goes lean, with nurses playing a key role in the culture change.

Kimberly T. Komer, MBA, RN, NE-BC Nicole M. Hartman, MSN, RN Angela Agee, ADN, RN, CMSRN Maria McNally, BSN, RN, CMSRN

47 The OR Connection

Aligning practice with policy to improve patient care 47

Hospitals increasingly are implementing quality-improvement systems based on “lean” principles derived largely from the Toyota Production System (TPS). This system, which divides all manufacturing activities into those that add value and those that create waste, aims to eliminate waste and maximize value. Lehigh Valley Health Network (LVHN), a 988-bed Magnet™ organization in eastern Pennsylvania, is committed to a formal approach of lean methods, termed the System for Partners in Performance Improvement (SPPI).

The goal is to discover more efficient ways to provide health care by using lean tools and concepts that reduce waste and repetition. SPPI aims to identify and remove obstacles to service delivery using two simple concepts: 1) respect for people, patients, and society 2) c  ontinuous improvement

Focusing on these concepts guides LVHN staff to deliver excellent care while reducing costs and improving efficiency. LVHN services a population of about 700,000. Its nearly 10,000 employees include approximately 2,400 nurses. In 2008, it embarked on the SPPI journey, which built on the existing culture of performance improvement. SPPI allows nurses at all levels to influence changes throughout LVHN—a key characteristic of a Magnet organization.

Eliminating waste TPS concepts have been used in the business world for decades and have become popular in health care. Healthcare leaders believe patients are willing to pay for quality care—that they go to the hospital to be diagnosed, treated, and discharged, but aren’t willing to pay for more than that (deemed waste). So how do you remove waste from hospital processes to improve efficiency and patient outcomes? Before waste can be removed, it must be identified clearly. TPS identifies seven non-value-added wastes in business. In his 2009 book, Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction, Mark Graban modified the definitions of these wastes to apply to health care. (See table on the next page, “Eight Wastes in Health Care.”)

48 The OR Connection

Eight Wastes in Health Care The seven non-value-added wastes identified in the Toyota Production System have been expanded to eight and modified for health care, as represented by the acronym and mnemonic U-WITH-D-MOP.


Examples • Untapped creativity Unused human potential

• Untapped talent • Injuries





• Delay in patients, providers, and materials

• Stacks of work • Piles of supplies

• Transporting people and paperwork

• Wrong information • Need to repeat work already done

• Finding information by going through the physical motions Motion

• Double entry of data • Searching for data, patient information, etc



• Duplication • Extra information

• Extra steps and checks • Workarounds

Continued on page 51

Aligning practice with policy to improve patient care 49

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Defining a value stream The journey to go lean begins with defining a value stream—the specific process used to provide a service to customers. To do this, LVHN’s senior leadership had to answer such questions as: What do patients want from LVHN? What are they willing to pay for? As they did so, they defined a value stream focusing on improving access and use of services. Then they broke this concept down into value stream 1, which centered on inpatient services, and value stream 2, centering on perioperative services. Once the value streams had been defined, the new goal was to make value flow seamlessly through all departments to ensure excellent, efficient care. Each unit or department has a specific function; interactions among departments can make or break the patient experience. All areas and departments affected by a process must participate in strategies aimed at removing waste and improving efficiencies.

The five days of an RIE To improve the value flow, the SPPI process used rapid improvement events (RIEs) for each area identified in the value stream. An RIE is a 5-day, continual-improvement event geared toward identifying wastes in a process, developing and testing possible solutions through experiments, and implementing changes to improve service to customers. The RIE was conducted at the site of the problem. Members selected for each RIE included frontline staff and management from all units involved with the process, as well as “outside eyes” (persons with no direct involvement in the process change). Value stream 1 consisted of seven different RIEs.

For each day of the RIE, participants strove to accomplish a specific goal: Day 1: Define the current state—the process taking place at this moment. Day 2: Create the target state—where you want to be, the direction in which you want to go. The target state may not be your final result because it evolves over time; at some point, it becomes the current state again and the process begins anew. Experiments (solutions or countermeasures) are developed to eliminate waste. Day 3: Take action by testing the experiments developed on Day 2 to achieve the target state. Some experiments may fail, but these failures let you tweak the countermeasures to find what works best. Day 4: Identify the process that effectively eliminates waste and improves the value stream. Finalize the new process and develop standard work to achieve the target state. Identify metrics to measure the effectiveness of the new process. Day 5: Report to the organization and celebrate successful RIE completion. The team shares the new process and standard work done to achieve the target state. Information sharing is crucial to sustaining changes. However, checkins must be done at 30, 60, and 90 days, when necessary changes can be made. The “feed forward” process continues with each change to ensure the target state becomes the new current state.

Throughout the RIE process, lean tools and concepts were used to detail the current state, conduct experiments, and develop processes to achieve the target state. (See table on the next page, “Going Lean: Tools and Concepts.”

Aligning practice with policy to improve patient care 51

Going Lean: Tools and Concepts During the System for Partners in Performance Improvement process, the Lehigh Valley Health Network used the lean tools and concepts below to detail the current state, conduct experiments, and develop processes to achieve the target state.

Lean tool or concept

Description and purpose

Communication circle: visual mapping of all communication in all directions among all people involved

• • • •

Reveals the number of stakeholders involved Exposes all communication channels Displays movement of information Visualizes waste of overprocessing information

Spaghetti diagram: visual mapping of all physical movements in all directions among all people involved

• • • • •

Visualizes movement of people in work area Exposes wastes of motion and transportation Reveals inefficient layouts Displays long distances traveled between process steps Identifies material and information flow through process

Process mapping: visual mapping of all steps of process

• Visualizes process from customer’s eyes • Identifies value and non-value-added process steps • Provides a common framework

65 sequence: procedure to remove waste, improve efficiency, and standardize steps of a process to achieve and sustain target state

• Sort: Remove items not needed daily. • Set in order: Label items and make it obvious where they belong. • Shine and sweep: Clean and inspect everything inside and out. Visually sweep area to make sure everything is in its place. • Safety: Display required safety information and clearly identify exits wand emergency equipment. • Standardize: Establish policies and standard work. • Sustain: Develop training and detail daily activities or self audits to ensure that process change “sticks.”

Standard work: detailed process for everyone to follow when doing a task to ensure consistent results

• Details most efficient process to perform a service • Develops set of procedures to execute consistently for given task

Continued on page 54

52 The OR Connection

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Lean principles in action One area of needed improvement identified in value stream 1 was inpatient physical discharge. Here’s how LVHN used the RIE process to improve the discharge process. Day 1: Participants identified key discharge problems. These problems included lack of a standard discharge process and a majority of discharges occurring in the late afternoon, which created significant capacity issues. LVHN needed to establish standardized discharge expectations—not only for patients and families, but also for nurses and physicians. The current state was further defined using the following metrics: • average acute length of stay: 5.7 days • 5% of discharged patients left before 11 a.m., even though 46% of discharge orders were written or entered before 11 a.m. • average “order to discharge” elapsed time: 3.05 hours • 34% of discharges completed within 2 hours of order • 75% of discharges occurring after 1 p.m. Clearly, a communication gap existed among the interdisciplinary team, which caused a delay in discharges. Day 2: Participants determined the target state to delineate how the discharge process should be conducted to eliminate waste. Improvements in flow, patient satisfaction, and utilization were the desired outcomes. • Flow: Develop a standard collaborative discharge process to promote efficient communication among all multidisciplinary team members. • Patient satisfaction: Increase patient and family satisfaction with the robust discharge process. •  Utilization: Involve multidisciplinary team members at the patient’s bedside, including staff from all shifts. Next, the RIE team applied lean tools. A communication circle showing everyone involved in the discharge process was created to illustrate all interpersonal communications. A gap analysis was conducted by shadowing staff during the discharge process to identify where and when most discharge work occurred. When the RIE group analyzed the information gathered using lean tools, it became obvious that the discharge workload needed to be leveled out among all shifts and communication needed to be more frequent and more efficient.

54 The OR Connection

Value Stream 1: Outcome Metrics To track the success of implemented process changes, the metrics below were derived by project sponsors of the System for Partners in Performance Improvement process, in conjunction with participants from each of the seven rapid improvement events conducted for value stream 1.


Fiscal year 2008 (baseline)


Fiscal year 2009 (actual)

Glycemic control


> 75%


Overall patient satisfaction




Employee satisfaction (measured on a Likert scale of 1-5)




Cost/adjusted admission




Length of stay

6.02 days

5.45 days

5.52 days

Emergency department (ED) diversions

150.5 hours

0 hours

14.9 hours

Time from ED to bed

129 minutes

60 minutes

95 minutes


Patient flow

Aligning practice with policy to improve patient care 55

Days 3 and 4: Participants tested proposed experiments, which included posting door signs indicating a potential discharge, using a discharge checklist with assigned tasks for each shift, and instituting collaborative discharge rounds. The checklist included such items as resolving or completing care plans, conducting patient education, and reconciling patient belongings. A color-coded key on the checklist identified which tasks the discharging nurse must complete and which tasks other nurses could complete. Thus, on the day of discharge, it would be clear which tasks still needed to be resolved before the patient could be discharged. Throughout the RIE process, participants indicated that we needed to work at communicating better with each other. A successful experiment to help establish this was implementing a daily rounding process at 10 a.m. involving nurses, physicians, physician assistants, and case managers to discuss patient discharge plans. This procedure has been invaluable, further ensuring timely discharge and enhancing interdisciplinary communication. Day 5: “Feed forward” occurred. Successful experiments and newly developed standard work were reported to all of LVHN. Follow-up at 30, 60, and 90 days continued to show the new discharge processes were effective and the target state had been achieved.

Value stream 1 outcomes Overall, the SPPI effort at LVHN has reduced length of stay, improved patient satisfaction, decreased emergency department (ED) diversions, and reduced time from the ED to the bed. (See table, “Value Stream 1: Outcome Metrics, previous page.)

56 The OR Connection

Overall, the SPPI effort at LVHN has reduced length of stay, improved patient satisfaction, decreased emergency department (ED) diversions and reduced time from the ED to the bed. Although work remains to be done and new processes to further improve metrics continue, lean thinking has become enculturated among all LVHN staff. Many staff members now use these techniques throughout all aspects of their work. Living the RIE process has given staff at all levels a better understanding of organizational processes. As a Magnet organization, LVHN ensures that nurses stay at the forefront of organizational change. The lean tools and concepts used since SPPI inception have become part of daily nursing practice. The integral role nurses have played in SPPI is another example of what it means to work at LVHN. Going lean is a journey—one that allows us to continually improve our health network and the way we provide care to the community. Selected references Graban M. Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction. New York, NY: Productivity Press; 2009. Liker JK. The Toyota Way: 14 Management Principles from the World’s Greatest Manufacturer. New York, NY: McGraw-Hill; 2003. The authors work at Lehigh Valley Health Network in eastern Pennsylvania. Kimberly T. Korner is director of patient care services. Nicole M. Hartman is a nursing excellence specialist. Angela Agee is a staff nurse in the medical-surgical unit. Maria McNally is a patient care specialist in the medical-surgical unit. Reprinted with permission. American Nurse Today. Volume 6, Number 3.

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Naomi Judd How her tragic illness led to a healthcare safety crusade

58 The OR Connection

The OR Connection recently had the opportunity to interview country music Icon and registered nurse Naomi Judd about her experience with a needlestick that led to a diagnosis of Hepatitis C years later at the peak of her singing career.

Before her rise to stardom beginning in the mid-1980s, Naomi Judd was a single mother of two young daughters, Wynonna and Ashley, who was constantly struggling to make ends meet. Working various office and waitressing jobs, and picking up singing gigs here and there, she ultimately put herself through nursing school to make a better life for herself and her girls. “I worked as an RN in ICU at a hospital in Franklin, TN, while my girls were in school and before we started our singing career. And because of the fast-paced, life-and-death atmosphere of the unit, I received multiple needlesticks. I had people vomiting all sorts of bodily fluids on me. It was just part of my everyday shift. So I really didn’t think much of it back then. And this was 1983 – when I wore my last support hose – when I quit working. Actually, it was Valentine’s Day. I remember it very well. I remember taking Valentines for all the girls.” Naomi left nursing in 1983 to pursue her singing career with her daughter Wynonna. It would be many years until her Hepatitis C diagnosis.

“Those years – in 1983,” she continued, “we didn’t know much about AIDS, Hepatitis C. They never told us about Hepatitis B or any of the dangers we would be facing every time we walked onto the unit. I now know that 85 percent of the etiology is unknown when it comes to needlesticks. It’s just par for the course. I never once remember anyone being sent to the lab to get blood drawn to check for a blood borne disease. Of course, I realize now that Hepatitis C is a bloodborne disease. I’ve never had a tattoo, of course I’ve never done IV drugs. I’ve never had an organ transplant or a blood transfusion. I’ve never shared a razor or a toothbrush with anyone who had Hepatitis C. I’m pretty sure that I got Hepatitis C during my ICU days.”

Naomi’s journey with Hepatitis C “When I was first diagnosed, I was misdiagnosed. And for years before, no one paid attention to me. All the doctors said it was stress because of my travel schedule and my successful lifestyle challenges. I couldn’t get anyone to pay attention.”

Center photo: Before her singing career, Naomi Judd was an RN in an ICU where she endured multiple needlesticks.

Aligning practice with policy to improve patient care 59

Hepatitis C symptoms are vague—fatigue, nausea, depression— and can be attributed to many different conditions. And blood tests in the 1980s were not very reliable. “I fell through the cracks over and over again. Nobody checked again after I was given the very first prototype Hepatitis C test. I was told I was false-positive. I was negative: non-A, non-B, non-C in 1989. So I walked around for a long time thinking that I had this unknown liver inflammation. Of course, it was fulminating. I remember getting a liver biopsy, and that is the definitive test. The ALT and AST blood tests can vary. The gold standard will always be that pathology slide. It was not good. They told me I had less than three years to live.”

“I used everything that was good, that was enlightening. I tried to stay in the moment. I tried to stay in present-moment awareness with God. And anything that didn’t work, I flipped a mental switch and called it mental malpractice and got rid of it. “I live in nature. I have my four dogs. I don’t have a computer. I don’t have a cell phone. I stayed with people who are loving; who are kind. I kept an open mind. I worked through this with a feeling of hope. I say hope stands for Healing Of Painful Experiences. I tried to stay focused on the answers; I say I tried, because I did not always succeed because I was so ill. I used positive psychology and stayed focused on everything that made me feel comfortable and at peace and that kept me in the moment.”

Prevention is #1. My whole thing is prevention and wellness. I worked with OSHA to help them develop the retractable needle... As nurses, we have to stay extra vigilant. It’s a war zone. I’m sorry. It just is. And we have to face that reality.

Finally enjoying a successful singing career and all the financial rewards that come with it, Naomi’s Hepatitis C diagnosis was a huge emotional blow.

Naomi beat the odds. She calls herself a miracle. She said she has been cured of Hepatitis C since 1995. But her involvement with the disease and finding the absolute cure continues.

“But, I say he who looks back with regret dies with remorse. And the truth is, I would never have had medical coverage, I would never have had the resources that I did get because of becoming a celebrity. And it’s weird, but I have to tell you, in all of this, I somehow knew in my essence and my core that I was going to be OK.”

“I was very lucky. Because of my proactive stance, my pilgrimage to find the right doctor. I volunteered to be the Hepatitis C spokesperson for the American Liver Foundation, and I found a doctor – Dr. Bruce Bacon at St. Louis University. He was the medical advisor, and I was the media person, the face. We started working together.

Naomi put her music career on hold in 1991 to concentrate on her health. She studied the liver and its many functions. She looked for answers and never gave up. She fought severe depression, which is one of the many side effects of Hepatitis C. She sought high-quality medical care, psychological therapy and holistic methodologies including guided imagery, aromatherapy, music therapy, massage and biofeedback.

“Now I’m working with a neurologist in Naples, Florida, Dr. David Perlmutter. He’s very much in the vanguard, and we’re starting to put together a futuristic neurology clinic to help people understand how the mind controls the body. So one of my passions in life is to help find an absolute cure [for Hepatitis C]. And we are getting some fabulous results.”

60 The OR Connection

Safer needles “Prevention is #1. My whole thing is prevention and wellness. I worked with OSHA to help them develop the retractable needle. I mean how many times when we’re starting an IV – and we only have two hands – and we’re starting the butterfly and we’re taping it down, and we stick that needle into the chux or into the mattress. “For three pennies, OSHA developed the retractable needle. We’re always looking for ways to prevent these things. As nurses, we have to stay extra vigilant. It’s a war zone. I’m sorry. It just is. And we have to face that reality.”

Don’t be afraid to speak up Naomi has been an advocate for prevention going back to her nursing school days. In her autobiography, Love Can Build a Bridge, she wrote there were several times when her somewhat outspoken nature and desire to do the right thing almost got her kicked out of nursing school. One time, in the newborn nursery at a hospital in Kentucky, she observed that the physician failed to wash his hands as he entered. In front of all the other nursing students, Naomi walked up to the doctor to gently remind him he’d forgotten to wash his hands. She wrote, “The doctor’s oversize ego and my instructor’s embarrassment got me a stern admonishment, but I felt I’d done the right thing. A germ can spread like wildfire through a nursery and wreak havoc on its tiny, fragile victims.”

Naomi has been an advocate for prevention since her nursing school days in the 1970s.

Naomi was certainly ahead of her time, promoting handwashing and prevention of hospital-acquired infections – and speaking up among her healthcare peers – all the way back in the late 1970s. She continued in the interview, “Any time you walk into your workplace, it’s exciting. I think all nurses have a thrill gene. If I went back to work right now, there’s no doubt I’d be working the trauma bay at Vanderbilt because I like a high stimulation environment. But, we have to put ourselves first. You have to get out of your overflow. Nurses are incorrigibly bad at not taking themselves seriously, not putting themselves first.

Did You Know? It wasn’t until 1991 that OSHA published the first bloodborne pathogens standard to protect healthcare workers against risks posed by needlesticks, HIV and Hepatitis B and C.

Aligning practice with policy to improve patient care 61

ADVICE FOR NURSES 1. Always stay healthy. Do everything that you need to do.

2. Y  ou’re In Charge. Don’t ever let anybody else tell you who you are or what’s going to happen to you.

“The second thing is if you should get stuck, you need to get tested immediately. You need to file your reports, you need to cover your butt.”

Don’t ever let anybody else tell you who you are or what’s going to happen to you.

“Always stay healthy. Do everything that you need to do. Put that cigarette down, girl. Put that cigarette down. Stay away from that stupid vending machine. It breaks my heart.

“Tell nurses I love ‘em. It’s like an exclusive club. You know, when I’m with Dolly or Reba or Taylor Swift, or some of my girlfriends in the industry, we have our own language. We talk about, OK, who’s the best hairdresser in town now, and where’d you get that fabric, and watch out for this psycho fan.

“I love nurses. I’m still a nurse. Actually, this is ironic. I just got my nurse’s license in the mail this morning when I went to the mailbox. I’m inactive, but every year I send in my hundred bucks because it’s important to me.

“But with nurses, they’re just like my favorite people. I mean, I see a nurse, and you know, I just hug her. I feel like we have this common gene or something. Thank you all, thank you. Take care of yourselves.”

Focus on yourself and take care of you

“Especially since I’m still in the field, and I’m starting to develop this neuroscience clinic. I’m going to be in it more than ever. “But the other thing is to realize that whatever happens, you’re in charge. I felt so completely helpless and you have to understand that [when you face a serious illness] it is a journey.

62 The OR Connection

Exposure to Bloodborne Pathogens

Get the Facts !


600,000 to 800,000 needlestick injuries occur each year.1”

Completely automatic safety devices are more effective for needlestick prevention compared to devices with automatic or semi-automatic safety features.2

10 times

1 in 2 nurses experience blood exposure on their skin or in their eyes, nose or mouth at least once a month when inserting or removing peripheral IV catheters. 5

Although 86% of nurses say their department strongly encourages and supports reporting needlestick injuries, 74% of nurses say needlestick injuries still are underreported.3

43% of injuries in the O.R. are attributed to suture needles.4

Tips for Avoiding Blood Exposures and Percutaneous Injuries in the Operating Room4 n Use instruments, rather than fingers, to grasp needles, retract tissue and load/unload needles and scalpels n Give verbal announcements when passing sharps n Avoid hand-to-hand passage of sharp instruments by using a basin or neutral zone n Use alternative cutting methods such as blunt electrocautery and laser devices when appropriate n Substitute endoscopic surgery for open surgery when possible n Use round-tipped scalpel blades instead of pointed sharp-tipped blades n Double glove

74% of nurses report being stuck by a contaminated needle.3

References 1. National Institute for Occupational Safety and Health (NIOSH). How to protect yourself from needlestick injuries. Available at: Accessed March 9, 2012. 2. Pyrek KM. Study raises ongoing issue of passive vs. active safety-engineered sharps devices. November 2, 2010. Available at: Accessed March 9, 2012. 3. American Nurses Association. 2008 Study of Nurses’ Views on Workplace Safety and Needlestick Injuries. Available at: (ANA/Invira) 4. Centers for Disease Control and Prevention. Workbook for Designing, implementing, and Evaluating a Sharps Injury Prevention Program. Available at: Accessed March 9, 2012. 5. O’Connor D. The most dangerous job in surgery? Outpatient Surgery Magazine. March 7, 2012. Available at: Accessed March 9, 2012.

Aligning practice with policy to improve patient care 63

Medline Safety Syringes

Protect yourself and patients from needlestick injuries Safety features so you won’t get stuck A staggering 74 percent of nurses report being stuck by a contaminated needle,1 which can lead to infection with Hepatitis B and C, HIV, and other dangerous bloodborne pathogens. Avoid needlesticks with Medline Safety Syringes. After injection, slide the safety shield forward and simply twist clockwise. Once you hear a click, the needle is fully protected and the syringe is ready for safe and proper disposal.

To Prevent Transmission of Infections in Healthcare

Medline Safety Syringes also feature: • Low dead space design to reduce medication waste and expense

Injection Safety is Every Provider’s Responsibility

• Easy-to-read bold markings • Insulin and tuberculin versions

©2012 Medline Industries Inc. Medline is a registered trademark of Medline Industries, Inc.

Reference 1. American Nurses Association. 2008 Study of Nurses’ Views on Workplace Safety and Needlestick Injuries. Available at: Accessed March 16, 2012.

Special Feature

Medication Safety in the Operating Room What is your role? By Jayne Barkman, BSN, RN, CNOR Many factors can lead to medication errors in the operating room. The types of procedures performed today are technical and complex, and the patient acuity is more severe. Benchmarks such as room turnover times must be met, and distractions are common throughout most procedures. Medication orders are often obtained from the surgeon preference cards which may not be up-to-date. Verbal medication orders are given through a surgical mask, and clinicians may be assigned to an unfamiliar service specialty or procedure. High alert meds such as epinephrine and the “caines� are available in multiple concentrations and dosage forms in the operating room. Additional factors influencing medication errors in the OR include: labeling issues when medication is transferred to the

Aligning practice with policy to improve patient care 65

sterile field, poor communication during handoff or end-of-shift reports, knowledge deficits related to medications, and drugs taken from a supply cabinet after the cabinet has been rearranged or restocked.1,2 According to the Joint Commission Sentinel Alert Report through September 2011, medication errors were the ninth most frequently reported sentinel event that resulted in death or serious outcomes.3 Since not all sentinel events are reported, it is difficult to ascertain the number of medication errors that actually occurred.

Medication Basics for the Operating Room • Verify medications visually and verbally between two qualified people. • Label medication as soon as it is prepared. • Make sure medications both on and off the sterile field are labeled with the proper name, strength, quantity, diluents, volume and an expiration date if the med is not used within 24 hours. • Consider pre-printed labels. Always use a non-smearing pen to mark blank labels. • Familiarize yourself with the medications used during your assigned procedures. • Avoid distractions when drawing up and delivering medications to the sterile field. • Review surgeon preference cards for medication accuracy and update routinely. • Make sure drug references are easily accessible for all perioperative nursing staff via the hospital intranet and hard copy. • During endoscopic procedures, ensure there is adequate lighting when drawing up and dispensing medications. • If music is playing in the operating room, keep the volume low. • Suggest a medication module be included in the staff’s annual unit competencies. • Be aware of patient drug and food allergies. • Ask for a detailed history of any over-the-counter and homeopathic medications the patient is taking. • Contact the hospital pharmacy if you have any questions pertaining to medications. • Be your patient’s voice. Speak up and question medications and doses.

66 The OR Connection

According to an analysis of almost 700 operating room medication error reports prepared by the U.S. Pharmacopeia (USP), two of the most common medication errors in the operating room were related to the administering mode of the medication and the improper dose/quantity given.1 As a perioperative nurse, what can you do to ensure medication errors do not occur? Get back to the basics. Be methodical, and avoid distractions to keep your patients safe.

Remember the Five Rights of Medication Administration


The Right Patient


The Right Medication


The Right Dose


The Right Time


The Right Route

References 1. Becker SC & Hicks RW. Medication Errors in the Operating Room. U.S. Pharmacopeia.

Available at:

html. Accessed February 1, 2012.

2. Medication Errors in the OR. Patient Safety Tip of the Week. March 24, 2009. Available

at: Accessed

February 1, 2012.

3. Joint Commission Sentinel Events. Available at

assets/1/18/3Q2011_SE_Stats_Summary.pdf. Accessed February 1, 2012.

Aligning practice with policy to improve patient care 67

Rounding Up Compliance OR staff improves sharps safety by making it fun

68 The OR Connection

Vangie Dennis, BSN, RN, CNOR, CMLSO, Administrative Director, Spivey Station Surgery Center outside Atlanta, knows how to get her staff’s attention when it comes to safety and compliance – make it fun! During procedures the “neutral zone” is the holding area for a few surgical instruments, including sharps. The “passing zone” is where a single item is laid down specifically for another person to pick up. This prevents surgeons and nurses from putting themselves in danger of cutting themselves by having to reach in among multiple sharps to find the item they need. To enhance sharps safety in the OR, Vangie organized a “Neutral Zone Round-Up.” Designated “neutral zone sheriffs” wore badges and policed the neutral zone for compliance. They ticketed people they observed using the neutral zone, and each ticket could be cashed in for a candy bar. All tickets were placed in a bucket for a weekly drawing for $10 movie and restaurant gift cards. Compliance data was recorded and displayed on a “Neutral Zone Roundup” bulletin board. Ticket winners’ photos were also displayed as “Most Wanted” for compliance. “The rewards weren’t worth much, but you’d be surprised how much they made our staff want to be involved in our safety efforts,” Vangie said. Feeling left out, surgeons even began asking to participate in the fun compliance activities.

Aligning practice with policy to improve patient care 69


DEAD! 70 The OR Connection

By Wolf J. Rinke, PhD, RD, CSP

Erik Weihenmeyer successfully climbed Mt. Everest and four of the worlds’ tallest peaks. No big deal, right? Wrong! It’s a very big deal because Erik is BLIND! Contrast that to the fact that many of us have difficulty tackling even the most mundane challenges. For example you may be afraid of asking for that raise you know you have earned. If you’ve had a disagreement with your boss you may be afraid to talk to her about it. Or you may be avoiding to get in touch with that wonderful young man you met at the party last weekend. What prevents most of us from being more like Erik? It’s that dirty four letter word: FEAR! Here are six specific strategies you can use to help you get rid of fear.

Aligning practice with policy to improve patient care 71

e It

1. Acknowledg

Acknowledging that fear of failure is normal allows us to see ourselves as typical human beings instead of “chickens.” It provides us with the mechanism for getting off our case. For most of us, we are the ones who hold us back more than anything or anyone else. Some time ago I shared a taxi with a young man on my way from Chicago’s O’Hare airport to downtown Chicago. He told me that he worked for CBS and was on his way to make a big presentation to the CBS board of directors. When I told him that I was a professional speaker, management consultant, and author he got excited. He immediately began to quiz me on how he could be a more effective presenter for this big meeting he had coming up. I asked him what he wanted to improve. After some prying, he told me he wanted to be less nervous. I asked him why he wanted to do that. When he gave me a funny look that said: Wonder what kind of professional speaker this guy is? I explained that speakers who are not nervous are terrible speakers because they are deadly. (Remember that professor that put you to sleep during every lecture?) I assured him that being nervous is a benefit, provided the nervous energy is channeled in the right direction. After coaching him, I left him with a thought that he eagerly wrote down: “Every speaker has butterflies. Excellent speakers make the butterflies fly in formation.” One week later he sent me a note together with an order for my book and audio program. In his note he told me that he had made his butterflies fly in formation and that he had made the best presentation of his life. (If you’d like help with this read Knock’em Alive Presentation Skills: How to Make an Effective Presentation for 1 or 1,000, 2nd Edition, (C208), 20 CPEUs, available at, or in an e-course format at htm#C208.)

72 The OR Connection

3. Do the Thing

2. Ignore othe


I have found over the years that the minute I announce an innovative idea, a new business venture, a great suggestion for an outing, or anything else that is different, there are innumerable people who tell me that it won’t work, is not feasible, or is too risky. The naysayer song goes on and on. If you have worked in a traditional healthcare organization, I know that you too have heard that song many times. That type of advice used to slow me down. It made me cautious, made me rethink my original thoughts, caused me to worry, and led me to focus on all the reasons why something could not work, dissipating my energy to the point that I could no longer see all the reasons why it could work. Before I knew it, I gave up on what might have been a milliondollar idea. Not anymore. I have developed a simple but powerful strategy to silence the naysayers by saying: “I appreciate your concern. Have you yourself done this before?” If the answer is no, I thank them for their interest and ignore their advice. On the other hand, if the answer is “yes” I listen attentively so that I can learn from their mistakes. I firmly believe that only the people who have taken the journey and who have experienced the risks are able to provide you with meaningful advice. Most of the others want to be sure that you remain one level below them so that they can feel OK about themselves. After all, if you succeed too much, it might lower their self-esteem.

You Fear

Think about what you fear the most, and do it. Probably the biggest confidence builder in your life is to do the thing you fear. It may be quitting your current job, jumping out of an airplane (do put on a parachute first, and, while you are at it, get some decent instructions too), living in the wilderness, scuba diving, or giving a speech. Do your homework, get yourself mentally and physically conditioned, and break the task into small, doable steps so that you can benefit from the principle of incremental success. For example, tightrope walkers start low to the ground. After they have it mastered at that height, they go up a little bit at a time. When they get dangerously high, they add a safety net. Only after they have mastered the task to the point that they could do it in their sleep do they remove the safety net. After experiencing incremental successes at whatever you are afraid of, you will be able to do it, and will no longer be afraid of it. Most importantly, it will empower you and put you in charge of your life, providing you with the confidence of a supremely successful human being.

4. Conduct a W orst-Case Analysis Whenever I am presented with a challenge that scares me, I ask myself, “What is the worst thing that can possibly happen?” After I identify that, I ask myself, Can you live with that? If the answer is yes, I forget the worst case, visualize myself succeeding, and go for it. If that does not work for you, do a basic Ben Franklin decision making analysis. (Actually Plato came up with it first.) For each option, list the “Pros” and “Cons.” Now pick the option that has the greatest number of Pros and the fewest Cons, and go for it with gusto. (For other useful decision making strategies go to wiki/Decision_making.)

Aligning practice with policy to improve patient care 73

h Desire

r wit 5. Replace Fea

All of us are motivated by two very powerful human emotions: fear and desire. Both are extremely powerful and both work equally well, although in opposite directions. To overcome fear, we must recognize that the human mind can only hold one major thought at a time. To take advantage of this phenomenon, we must get in the habit of substituting desire for fear when we communicate with ourselves and with others. Instead of programming our mind with the things we do not want to have happen we must use the same creative energy to tell ourselves what it is that we want to have happen. Telling ourselves what we want should be supplemented with visualizing what we desire in clear, vivid, dramatic pictures. Once you have formulated that picture in your mind, think of all the positive consequences associated with succeeding. That way you will be focusing on the rewards of success instead of the penalties of failure.

6. PIN it The PIN technique will help you focus on the positive instead of the negative, see the opportunity instead of the risks, and generally minimize “stinking thinking.” Internalizing and consistently applying the PIN technique has enabled me to transform myself from a perpetual pessimist into an eternal optimist. The PIN technique consists of a three-step mental process that you

74 The OR Connection

can use to first focus on what is positive (P), then on what is interesting or innovative (I), and last on what is negative (N). By PINing it, instead of NIPing it, you will provide yourself with the ability to focus your vast mental energies on positive thoughts instead of squandering them on negative and nonproductive ideas. NIPing it closes the proverbial mental shade whereas PINing it allows you to go beyond your customary response pattern and provides you with a technique that will let you see the hidden opportunities and focus on desire instead of fear. For other empowering strategies read or listen to Make It a Winning Life: Success Strategies for Life, Love or Business available at or if you need CPE credits devour How to Maximize Professional Potential and Increase Your Earning Power (C187) approved for 30 CPEUs, available at © 2011 Wolf J. Rinke

Judy Pickett

Running for Her

Life By Jennifer Freedman

With just a hint of the sun on the horizon, Judy Pickett laces up her running shoes, pulls on a windbreaker and heads out her front door. “Running is a part of me,” Pickett explains. “I love the time to decompress, pray and be alone.” Pickett considers every mile she logs a gift. The 48-year-old wife and mother battled three bouts of breast cancer over a five-year span. (continued)

Aligning practice with policy to improve patient care 75

PASSING THE TORCH: During treatment for her third bout of breast cancer, Pickett ran three races and carried the Olympic Torch for the 2002 Salt Lake City games.

It was November of 1996, when Pickett discovered her first lump. She was 33 and teaching high school science and weekly aerobics classes. She was the picture of health and happiness, but her body was under attack. “On Thanksgiving Day, we were having a holiday dinner and I had an itchy armpit,” says Pickett. “When I scratched it, I found a lump in my armpit and I knew that it wasn’t supposed to be there.” At such a young age and with no family history, it took three doctors and three months for Pickett to get a mammogram. The testing led to a grim diagnosis. “My doctor called at 5 p.m. on a Friday and I was home alone,” remembers Pickett. “He told me I had adenocarcinoma, stage two breast cancer. It was such a shocker. I really did not expect it. I was fine until my husband, Tod, came home and I told him. Then we both started crying and held each other. It was very scary. I thought to myself ‘this sort of thing is not supposed to happen at 33.” Pickett was emotional. A mom of three boys, the youngest just nine months old, she knew she had to fight back. She had surgery to remove the affected breast and nine cancerous lymph nodes, then nine months of chemotherapy and six weeks of radiation treatments. During treatment, Pickett says she relied mostly on Tod for support. He would accompany her to every appointment he could. He would talk to the nurses and even bring them gifts. Pickett also credits the nurses for helping her get through her rough days of treatment. In particular, she remembers her first oncology nurse at the infusion clinic.

76 The OR Connection

“We didn’t know how my body would react after the first chemo treatment, so she gave me her home phone number and said to call her if I needed to. It was a Friday afternoon and that night I was so sick. I called her on Saturday morning and she talked me through it. She told me everything would be okay and called in a prescription for an anti-nausea medication. She was truly compassionate.” Five months after completing chemotherapy, Pickett entered her first Susan G. Komen Race for the Cure in Sacramento. The race experience left her feeling so good that she decided to keep running. She started the Pink Ribbon Running Club and set a goal to run 100 benefit races in five years, supporting breast cancer awareness and research and spreading a message of hope for cancer survivors. “I wanted to demonstrate that breast cancer victims can not only survive, they can thrive,” says Pickett. But, in 1999, she hit a speed bump that would truly test her endurance. The cancer was back. Pickett wondered how this could be happening. “It was really devastating,” Pickett says. “I had to psyche myself up to go through it all again.” Her doctor recommended oophorectomy — surgery to remove her ovaries — where most of the estrogen in the body is made. Because estrogen makes hormone-receptor-positive breast cancers grow, reducing the amount of estrogen in the body or blocking its action can help shrink the hormone-receptorpositive cancers. Eight weeks post-op and Pickett was on the


To get your mammogram. Visit

Pink merchandise from Medline helps support the National Breast Cancer Foundation.

THE HEAT IS ON: By 2004, Pickett completed her one-hundredth race and was named one of eight running “Heroes” for 2004 by Runner’s World magazine. To date, she has run in 44 states, in 136 races alongside more than two million participants, including 200,000 survivors.

road again, running for her life. She ran ten races in ten weeks, winning the survivor division eight times. “Running was my coping mechanism,” says Pickett. “It was something that I could actually control during my cancer treatment.” But there were more hurdles. In August 2001, Pickett had a second recurrence of the disease. She found a lump during a self examination and it was on the same side. The cancer came back again. “This time it felt different,” says Pickett. “I was not as emotionally distraught because deep down I knew it could happen again. I really felt like kicking it.” Pickett had surgery to remove the lymph node and six rounds of chemo. While in treatment, she ran three races and carried the Olympic Torch for the 2002 Salt Lake City games. By 2004, Pickett completed her one-hundredth race and was named one of eight running “Heroes” for 2004 by Runner’s World magazine. To date, she has run in 44 states, in 136 races alongside more than two million participants, including 200,000 survivors. Her goal is to run in all 50 states.

78 The OR Connection

ALL IN THE FAMILY: Pickett was 33 and her youngest son, Zach, was just nine months old when she was first diagnosed with breast cancer. When he turned one, she brought him with her to the hospital. “I remember the radiation oncology nurses played with him and took care of him,” said Pickett. “They were great.”

“Running was my coping mechanism,” says Pickett. “It was something that I could actually control during my cancer treatment.”

“I am fortunate in that I feel strong and well enough to train and run races with other survivors so that I may spread my message to women with or without cancer,” says Pickett. “Medical research has made great strides in cancer therapy, which is allowing me to make great strides in my races and my life. Every time I cross a finish line, I’m declaring that life after breast cancer is not just about surviving, but also about thriving. It’s saying publicly to women everywhere that they can literally take steps to make their dreams come true.” Now a 10-year survivor, Pickett is teaching physical education and coaching track at a middle school in Sacramento. She says her life experience has enhanced the way she teaches. “I tell my students to have strength and courage and hope – no matter what,” says Judy. “I want them – and every young person out there to know – it is okay to question and persist. Be an advocate for your own health. It’s been 15 years since I was diagnosed and I’m still here. The longer I go cancer-free, the more inspirational I become.” Pickett’s Pink Ribbon Cancer Fund, which she and Tod started in 1999, has provided more than $72,000 in scholarships to high school seniors in the greater Sacramento are who have an immediate family member with cancer.

Just what I was  looking for.

CE Courses for Surgical Techs! Medline University continues to build its curriculum of Surgical Tech courses, available at Visit today to earn free CE credits with the following courses: • #2 on the Joint Commission List - Retained Foreign Objects • 9 on the Line to Improve Patient Safety • Applying Evidence-Based Information to Improve Hand-off • Communication in Perioperative Services • Safe Medication Practices in Perioperative Practice Setting Access courses on your computer, iPhone or iPad.

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2012 Medline’s AORN Breast Cancer Awareness Breakfast Welcomes Judy Pickett For the seventh year in a row, Medline hosted a complimentary breast cancer awareness breakfast on March 26, 2012, in conjunction with the Association of periOperative Registered Nurses (AORN) Congress in New Orleans, LA. Judy Pickett, a three-time breast cancer survivor and avid runner, shared her personal experience with breast cancer and how it is possible to not only survive, but thrive. Since 2006, more than 6,000 nurses have been inspired by the stories of survival shared at the breakfast. Past speakers include actors Jill Eikenberry and Michael Tucker, Olympic gold medal figure skater Peggy Fleming, TV journalist Linda Ellerbee, and actors Rue McClanahan and Ann Jillian.

Medline’s Breast Cancer Awareness Breakfast 2012

AORN 59th Congress March 26, 5:30-7:30 a.m. Keynote speaker: Judy Pickett Grand Ballroom at the Hilton New Orleans Riverside, Two Poydras Street, New Orleans

80 The OR Connection

A look back at previous breakfast forums 2011 Breakfast Forum at the AORN 58th Congress – Philadelphia, Pennsylvania

Last year, Medline’s 6th annual breakfast, held in conjunction with the AORN 58th Congress in Philadelphia, Pennsylvania, features Jill Eikenberry, a breast cancer survivor, and her husband Michael Tucker. Eikenberry and Tucker are veteran stage, film and television actors, perhaps best known for their portrayals of Ann Kelsy and Stuart Markowitz on the long-running hit television series L.A. Law.

2010 Breakfast Forum at the AORN 57th Congress – Denver, Colorado An audience of more than 1,200 operating room nurses, the largest to date, gathered to hear Olympic gold medalist Peggy Fleming talk about her skating career and battle with breast cancer. She did not disappoint the early morning crowd, who was also treated to a surprise appearance by several other celebrities of sorts – the staff members from Providence St. Vincent Medical Center in Portland, Oregon, who starred in the original “Pink Glove Dance,” a YouTube video sensation that has more than 13.1 million views to date.

2009 Breakfast Forum at the AORN 56th Congress – Chicago, Illinois

One of the funniest, frankest and most distinctive journalists to ever appear on television, keynote speaker Linda Ellerbee touched and inspired the crowd of 1,000 with her candid talk about her treatment and recovery. A 17-year breast cancer survivor, she said she was lucky because her training as a journalist taught her to ask the tough questions.

Photo by Gordon Munro

Aligning practice with policy to improve patient care 81

PGD Announcing ...

2012 Pink Glove Dance II Video Competition Begins July 2! What you can do now to get ready! 1. Get consent from your facility 2. Gather your friends and coworkers to participate 3. Start practicing Win a Donation to Your Favorite Breast Cancer Charity* • First Place: $10,000 • Second Place: $5,000 • Third Place: $2,000 Contest opens: July 2 Contest closes: September 28 Winners announced: November 2 Watch for further details and song choices at

*Subject to review and approval by Medline Industries, Inc.

82 The OR Connection

Some of last year’s PGD Video contestants!

Gwinnett Medical Center, Duluth, GA

Lexington Medical Center, West Columbia, SC

Highland Hospital, Rochester, NY

San Juan Medical Foundation, Farmington, NM

Victoria Hospital, Prince Albert, SK, Canada

Aligning practice with policy to improve patient care 83

Vaso-Force DVT Prophylaxis Quiet, comfortable, convenient care Innovative and effective DVT prevention • E  xcellent patient comfort with soft and breathable garment fabric • Extra comfort helps promote patient compliance • V  ery user-friendly for caregivers with easy-to-use troubleshooting guide clearly marked on machine • W  orks quietly to allow patients to rest, does not disturb clinicians • Both intermittent and sequential pumps availabe • Available with thigh, calf and foot garments

©2012 Medline Industries, Inc. VasoForce is a trademark and Medline is a registered trademark of Medline Industries, Inc.

SENSICARE Latex-free Surgical Gloves ®

Isolex™ - SensiCare’s Breakthrough Technology Medline’s SensiCare surgical gloves are made from Isolex, a proprietary syntetic polyisoprene. This material has a molecular structure that is virtually identical to natural rubber latex but without the harmful latex proteins. As a result, SensiCare surgical gloves are softer, more elastic and more comfortable than latex to satisfy clinical needs and support safety initiatives.

Advanced Performance and Protection

Ask your Medline representative about “Be Free Day” At no cost to your facility, Medline will provide a day’s worth of SensiCare surgical gloves as an opportunity to introduce your staff to the newest latex free technology. ©2012 Medline Industries Inc. Isolex is a trademark and Medline and SensiCare are registered trademarks of Medline Industries, Inc.

Healthy Eating

Nutrition Information Servings: 4 Calories: 197 Fat: 7.2 g Sodium: 80 mg Fiber: 7.1 g

Roasted Vegetables Ingredients 2 tablespoons olive oil 1 cup baby carrots 1 large onion, coarsely chopped 1 medium sweet potato, peeled and cut into 1-inch cubes 2 large beet, peeled and cut into 1-inch cubes 2 parsnips, peeled and cut into 1-inch cubes ¼ cup minced parsley Salt and pepper

Directions: Preheat oven to 500 degrees. Pour oil into large roast pan or jelly roll pan. Place pan into oven until oil is hot, about 1 minute. Add vegetables to hot pan and roast for 20-30 minutes, stirring every 10 minutes until vegetables are golden brown and sweet potato mashes easily when pressed. Season with salt and pepper and garnish with parsley. Diane Christensen, RN, is a clinical coordinator in the Quality division at Medline’s corporate headquarters in Mundelein, IL. She began learning how to cook at age 8, after her father

86 The OR Connection

passed away and her mother was working long hours. Diane started out helping prepare meals, and before long she was a full-fledged cook. “I still like cooking, and I am always looking for new things to try. Anytime I come across a new recipe, I adjust it to make it my own,” Diane said.

The Medline employee cookbook is $10. To purchase your own copy, please e-mail Judy at


Forms & Tools

The following pages contain practical tools for implementing patient-focused care practices at your facility.

Sharps Safety

One and Only Campaign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Sharps Safety Begins with You . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 First Aid for Exposure to Blood and Bodily Fluids. . . . . . . . . . . . . . . . . 96 Patient Safety

20 Tips to Help Prevent Medical Errors. . . . . . . . . . . . . . . . . . . . . . . . . 92 C. difficile

Six Steps to C. diff Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Surgical Fires

Know Your Role in Preventing Surgical Fires. . . . . . . . . . . . . . . . . . . . . 99

Aligning practice with policy to improve patient care 87

Program for Healthcare One-on-one sustainability guidance and services The greensmart approach for reaching your unique goals:

Measure Your Baseline


From calculations to benchmarking, your greensmart RoadMAP provides all the tools you need to green your OR, Housekeeping, Laundry, Food Services and Patient Rooms.


Receive One-on-one Consultation

3 4

You will receive personal assistance from your dedicated greensmart Program Manager.

Identify Green Products and Strategies With the help of your Program Manager, you will identify products, services and education that are right for your facility.

Monitor and Promote You are given the tools to not only monitor your progress, but to promote your success.

ONE CALL STARTS YOU ON YOUR WAY TO BECOMING GREENSMART Francesca Olivier, Medline’s corporate sustainability manager, is ready to work with you no matter where your facility is on your sustainability journey. Call her at (847) 643-3821 or email

Š2012 Medline Industries, Inc. greensmart is a trademark and Medline is a registered trademark of Medline Industries, Inc.

One and Only Campaign

Forms & Tools

1 needle 1 syringe



1 time

infections It’s elementar y! Patients and healthcare providers must both insist on nothing less than One Needle, One Syringe, Only One Time for each and every injection. For more information, please visit: The One & Only Campaign is a public health campaign aimed at raising awareness among the general public and healthcare providers about safe injection practices. Aligning practice with policy to improve patient care 89


Use silver to fight bacteria and surgical site infections Arglaes provides: • Antimicrobial protection for up to 7 days • Moist wound healing • Fewer dressing changes • Non-staining • Transparency for wound monitoring

The Arglaes family of products has something for every incision: • Arglaes Film is ideal for managing bacterial penetration on post-op incision and line sites. • Arglaes Island features a calcium alginate pad for fluid management.


Download a QR Code Reader app

2 Launch the QR app 3 Scan this QR Code or visit ©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Arglaes is a registered trademark of Giltech Limited Corporation.


11:13 PM

Page 1




Let’s get to the point.

Sharps Safety begins with you.

Anticipate injury risks.

Keep exposed sharps in view

Be responsible for

features. Dispose in sharps containers.

the sharps you use. Activate safety


beds and waste receptacles.

inspect for unprotected sharps in trays,

and under your control. Visually


work area with prevention in mind.

Prepare the patient and organize the


Sharps Safety Forms & Tools

Aligning practice with policy to improve patient care 91

Forms & Tools

Patient Handout - 20 Tips

20 Tips To Help Prevent Medical Errors One in seven Medicare patients in hospitals experience a medical error. But medical errors can occur anywhere in the health care system: In hospitals, clinics, surgery centers, doctors’ offices, nursing homes, pharmacies, and patients’ homes. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports. They can happen during even the most routine tasks, such as when a hospital patient on a salt-free diet is given a high-salt meal.

Medicines 1

Make sure that all of your doctors know about every medicine you are taking. This includes prescription and over-the-counter medicines and dietary supplements, such as vitamins and herbs.


Bring all of your medicines and supplements to your doctor visits. “Brown bagging” your medicines can help you and your doctor talk about them and find out if there are any problems. It can also help your doctor keep your records up to date and help you get better quality care. Make sure your doctor knows about any allergies and adverse reactions you have had to medicines. This can help you to avoid getting a medicine that could harm you. When your doctor writes a prescription for you, make sure you can read it. If you cannot read your doctor’s handwriting, your pharmacist might not be able to either.

Most errors result from problems created by today’s complex health care system. But errors also happen when doctors* and patients have problems communicating. These tips tell what you can do to get safer care.

What You Can Do to Stay Safe The best way you can help to prevent errors is to be an active member of your health care team. That means taking part in every decision about your health care. Research shows that patients who are more involved with their care tend to get better results.



*The term “doctor” is used in this flier to refer to the person who helps you manage your health care.


92 The OR Connection

Patient Handout - 20 Tips





Ask for information about your medicines in terms you can understand—both when your medicines are prescribed and when you get them: What is the medicine for? How am I supposed to take it and for how long? What side effects are likely? What do I do if they occur? Is this medicine safe to take with other medicines or dietary supplements I am taking? What food, drink, or activities should I avoid while taking this medicine? When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed?


Forms & Tools

Special devices, like marked syringes, help people measure the right dose. Ask for written information about the side effects your medicine could cause. If you know what might happen, you will be better prepared if it does or if something unexpected happens.

Hospital Stays

If you have any questions about the directions on your medicine labels, ask. Medicine labels can be hard to understand. For example, ask if “four times daily” means taking a dose every 6 hours around the clock or just during regular waking hours. Ask your pharmacist for the best device to measure your liquid medicine. For example, many people use household teaspoons, which often do not hold a true teaspoon of liquid.


If you are in a hospital, consider asking all health care workers who will touch you whether they have washed their hands. Handwashing can prevent the spread of infections in hospitals.


When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will follow at home. This includes learning about your new medicines, making sure you know when to schedule follow-up appointments, and finding out when you can get back to your regular activities. It is important to know whether or not you should keep taking the medicines you were taking before your hospital stay. Getting clear instructions may help prevent an unexpected return trip to the hospital.


Aligning practice with policy to improve patient care 93

Forms & Tools

Patient Handout - 20 Tips

Surgery If you are having surgery, make sure that you, your doctor, and your surgeon all agree on exactly what will be done. Having surgery at the wrong site (for example, operating on the left knee instead of the right) is rare. But even once is too often. The good news is that wrong-site surgery is 100 percent preventable. Surgeons are expected to sign their initials directly on the site to be operated on before the surgery. 13 If you have a choice, choose a hospital where many patients have had the procedure or surgery you need. Research shows that patients tend to have better results when they are treated in hospitals that have a great deal of experience with their condition. 12

Ask a family member or friend to go to appointments with you. Even if you do not need help now, you might need it later. 18 Know that “more” is not always better. It is a good idea to find out why a test or treatment is needed and how it can help you. You could be better off without it. 19 If you have a test, do not assume that no news is good news. Ask how and when you will get the results. 20 Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources. For example, treatment options based on the latest scientific evidence are available from the Effective Health Care Web site ( Ask your doctor if your treatment is based on the latest evidence. 17

Other Steps Speak up if you have questions or concerns. You have a right to question anyone who is involved with your care. 15 Make sure that someone, such as your primary care doctor, coordinates your care. This is especially important if you have many health problems or are in the hospital. 16 Make sure that all your doctors have your important health information. Do not assume that everyone has all the information they need. 14


94 The OR Connection

C. diff Prevention


Forms & Tools


to C. diff Prevention 1

Prescribe and use antibiotics carefully. About 50 percent of all antibiotics given are not needed, unnecessarily raising the risk of C. difficile infections.


Test for C. difficile when patients have diarrhea while on antibiotics or within several months of taking them.


Isolate patients with C. difficile immediately.


Wear gloves and gowns when treating patients with C. difficile even during short visits. Hand sanitizer does not kill C. difficile, and hand washing alone may not be sufficient.


Clean room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with C. difficile has been treated there.


When a patient transfers from one facility to another, notify the new facility if the patient has a C. difficile infection. Source: Centers for Disease Control and Prevention Available at:

Aligning practice with policy to improve patient care 95

Forms & Tools

First Aid

First Aidaidfor Exposure to Blood and Bodily Fluids 4.3.1 First The first aid given is based on the type of exposure (e.g. splash, needle-stick or other injury) and the means of exposure (e.g. intact skin, nonintact skin) (14, 72). Table 4.1 shows the first aid to apply in different situations. Table 4.1 First-aid care of the exposure site Injury or exposure Needle-stick or other sharps injury

Management Immediately wash the affected area with soap and water Allow injury to bleed freely

Splash of blood and/or body fluids on nonintact skin

1. Immediately wash the affected area with soap and water 2. DO NOT use disinfectant on skin 3. DO NOT scrub or rub the area

Splash of blood or body fluids to eyes

Flush the area gently but thoroughly with running water or saline for at least 15 minutes while the eyes are open Keep eyelid gently inverted

Splash of blood or body fluids to mouth or nose

1. Immediately spit out the blood or fluids and rinse the mouth with water several times 2. Blow the nose and clean the affected area with water or saline 3. DO NOT use disinfectant

Splash of blood and/or body fluids on intact skin

Immediately wash the affected area with soap and water DO NOT rub the area

World Health Organization Best Practices for Infections and Related Procedures Toolkit

96 The OR Connection

The OR Goes Green – the first and only bio-based surgical drape Medline’s EcoDrape is the only bio-based surgical drape available today. It’s made of more than 96% wood pulp and has all the same great features and performance as other Medline drapes, including hook-and-loop line holders, large reinforcement zones, and premium tape and incise film flush to the fenestration.

Composition Comparison EcoDrape SMS

Try the new EcoDrape and take your OR to the next level of green!

For a quick online video demonstration, visit


More than 96% wood pulp

No wood pulp

Petrochemical ingredients (plastics)


100% PP


Bio-based Fluorine


Download a QR Code Reader app

2 Launch the QR app 3 Scan this QR Code or visit

©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. EcoDrape nd greensmart are trademarks of Medline Industries, Inc.

Stick with OctylSeal™

Flexible wound closure that’s easy on your budget Introducing Medline’s OctylSeal high viscosity tissue adhesive for closure of simple wounds • Flexible structure moves with the skin, minimizing the chance of cracking • Acts as a barrier to microbial penetration as long as the adhesive film remains intact • 40 percent more glue per container than most other tissue adhesives (0.7 grams versus 0.5 grams) • Easy, versatile application – interchangeable tips (swab and nozzle) included in every package; violet color for easier identification on skin • Metal tube instead of glass ampule means no risk of broken glass entering the wound

Indications for use

Topical application only to hold closed easily approximated edges of wounds from surgical incisions, including punctures from minimally invasive surgery and simple, thoroughly cleansed trauma-induced lacerations. OctylSeal may be used in conjunction with, but not in place of deep dermal sutures. Available by prescription only.


Download a QR Code Reader app

2 Launch the QR app 3 Scan this QR Code or visit

©2012 Medline Industries, Inc. Medline is a registered trademark and OctylSeal is a trademark of Medline Industries, Inc.

Preventing Surgical Fires

Forms & Tools

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Subscribing to The OR Connection guarantees that you’ll continue to receive this magazine and won’t miss out on our industry updates and articles addressing on-the-job issues and patient safety.

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Myrna Chang, DHA, RN, CNOR Myrna worked in collaboration with Medline to design an innovative new line of the industry’s first long-sleeved scrubs. The design was a response to AORN and OSHA guidelines, which advise non-scrubbed personnel to wear long sleeves in the OR to prevent skin shedding, which can lead to surgical site infection. Source: AORN Fire Safety Tool Kit. Copyright ©AORN, Inc. Denver, CO; 2011. All rights reserved. Reprinted with permission.

Aligning practice with policy to improve patient care 99


The Aligning practice with policy to improve

patient care

Volume 7, Issue 1

Myrna Chang


PerforMAX scrubs

Covered Arms Are Compliant Arms

Part of Medline’s line of products.


Naomi Judd

Talk to your facility’s Medline rep or visit to find out more about PerforMAX scrubs.

©2012 Medline Industries, Inc. PerforMAX and greensmart are trademarks and Medline is a registered trademark of Medline Industries, Inc.

Collaboration Communication


The latest AORN and OSHA guidelines recommend that OR nurses who aren’t in gowns should wear long sleeves.

These sleeves are like the finest athletic undergear: cool, supportive and totally breathable. And because they’re PerforMAX, you get a fashionable layered look that’s comfortable and functional all shift long.



Medline innovation triumphs again.

PerforMAX scrubs added an inner sleeve to keep arms covered without dangling cuffs—like on jackets—to contaminate sterile fields.

Innovative scrub design enhances patient safety

Tragic Illness Leads to a Healthcare Safety Crusade MKT212065 / LIT1012 / 30M / QG5


Pink Glove Dance II Video Competition! Page 82


OR Connection Volume 7 Issue 1  

Medline's OR Connection Magazine, Volume 7, Issue 1 - FREE CE: Targeting Wrong Site Surgery Risks