723 / Differentiation of clear solutions in surgery.

FRANCE
Classification of the PSP
Type of Patient Safety Practice Not Evaluated
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Medication / IV Fluids
Medical devices / Equipment There is no specified text here
Topic of the reported practice
Patient safety system
Aim and the benefit of the Patient Safety Practice
 
This patient safety practice aims at reducing errors when using clear solutions on the operating theater. For example using antiseptic solutiion instead of local anesthetic (xylocaine).
Description of the Patient Safety Practice
 
Safe Clinical Practice: Differentiation of clear solutions in surgery. Reduce the risk of confusion of clear antiseptic solutions with local anaesthetic solutions in surgery.

Actions proposed to reduce risk:
Prevention:
    -to differentiate products:
        .mandatory:
            .do not pepare products in advance. Keep them in their labelled packaging until you need to use them.
            .use different type of containers (size,shape:sterile basin for skin disinfection and small sterile cup for local anesthetic) for different types of solutions.
        .recommended:
            .use coloured antiseptic for skin cleaning
            .avoid deconditioning products and using unlabelled recipients. Anytime it is possible draw the product directly from its original packaging.
    -double check:
        .mandatory:
            .when passing a medication to the licensed professional performing the procedure, the nurse who prepared the medication visually and verbally verify it by reading the medication label aloud (4 eyes principle).
        .recommended:
            .limit the number of HC professionals involved (the licensed professional performing the procedure is also preparing the medication)
    -Discarding unused products:
        .mandatory:
            .Discarding unused solution from the surgical field immediately after the treatment is provided (here, the antiseptic solution)
        .recommended:
            .Modify preoperative process: site identification (drawing), alcohol based skin sterilisation and anesthetic injection before desinfection and sterile draping to avoid product errors and improve adrenergic effect.

Error recovery:
    -stop injection in case of abnormal pain or any unexpected clinical sign
    -product checking
    -discarding products in case of doubt regarding their nature

Control of clinical consequences:
    -patient disclosure and agreement for rapid surgical intervention on the area of necrosis.
    -take pictures of the area of necrosis.
Attachment of relevant written information and/or photos, as appropriate
81_WP4_SSP_confusion_injectable_9.pdf
There is no specified text here
There is no specified text here
There is no specified text here
Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, partly
Level of implementation of reported practice
Unit or ward level
Specific and measurable outcome for the reported practice were defined
Not known
A baseline measurement before implementation of the reported practice was obtained
Not known
A measurement after full implementation of the reported practice was obtained
Not known
Evaluation of a "positive" effect of the reported practice on Patient Safety
Effect not known or the intervention has not yet been evaluated
Type of before-and after evaluation
There is no specified text here
Enclosure of a reference or attachment in case of published evaluation's results
There is no specified text here
There is no specified text here
Health care context where the Patient Safety Practices was implemented
 
Hospital
Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Not known
Specification of implementation in another health care setting(s)
There is no specified text here
Successful implementation's level  of this Patient Safety Practice across settings
There is no specified text here
Involved health care staff
 
Physicians
Nurses
Health care assistants
Risk manager
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
No
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
There is no specified text here
Point of time in which service user or their reprasentatives' involvement takes place
There is no specified text here
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
There is no specified text here
Short description of the service users' level of involvement
There is no specified text here
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
Not known
List of sources where public information is accessible
There is no specified text here
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
No
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
Not known or not relevant
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
There is no specified text here
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
There is no specified text here
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
No
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Yes
Costs of the Patient Safety Practices
 
Completion of cost calculation related to this Patient Safety Practice
No
Total number of person days required to implement this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
There is no specified text here
Contact information
 
Name: Jean Bacou
Country: FRANCE
Organisation: HAS
E-mail: j.bacou@has-sante.fr
Phone: +33 1 55 93 73 37
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