Computers and records

1Why it matters

Every case runs on information: who the patient is, which operation is planned, which surgeon is doing it, what that surgeon needs, which trays and drugs go into the room, and what happened during the case. Today most of that information lives in computers. Information technology means creating, storing, sending and finding information with computers and other electronic equipment. It is built into much of the equipment and many of the devices used around surgery.

Used well, computers make care safer. Electronic records cut transcription errors and help caregivers talk to each other. Bar-code scanning of medications has been linked with fewer drug errors, and tracking systems can tell sterile processing where a tray is at any moment.

Used carelessly, the same systems open new ways to harm a patient: a screen left open for anyone to read, a password shared with a coworker, a phone that pulls your eyes off the field. And a computer never takes the place of your own check. Count technology, for example, is used on top of the manual count, which the team still does in full.

The Core Curriculum asks you to describe the basic parts of a computer system, to evaluate the electronic medical record systems you will use, to evaluate safe practice with information technology, and to describe the best ways to secure a patient's protected health information. This chapter does all four.

Other chapters hold the pieces around it. Chapter 15 keeps the law: HIPAA's Privacy Rule, protected health information and the rules for documentation. Chapter 16 teaches email manners; chapter 12 medication safety; chapter 17 the hospital's communication systems and records in a disaster; chapter 21 robotic surgery and chapter 23 navigation and the room's equipment; chapter 27 instrument tracking as a sterile processing step; chapter 28 the preference card's contents, the counts, patient identification and the time-outtime-outTYM-owtA pause just before a procedure when the whole team confirms the right client, procedure and site; also, a short break to calm a child.Full entry Close as steps; chapter 29 the closing counts and implants; chapter 30 wiping down the computers at the end of a case; and chapter 31 patient transport.

2Computers in surgery

What the team uses them for

Computers touch almost every part of a case. You will meet them in these jobs:

• The patient's record: secure computer systems hold the patient's chart and other medical records. Many facilities put a computer in each operating room so the team can complete the OR record there and save it to the patient's chart.
• The schedule: surgery is booked through a scheduling office using a computer program. The schedule is easy to update, and it can be printed or sent to the surgical staff and other departments before surgery.
• Preference cards: each surgeon's choice of equipment, supplies, positioning and other details for a procedure.
• Orders and results: from the OR's computer, the team can send lab and radiology requests and receive the results in the room, and send requests to other departments such as sterile processing.
• Images: imaging equipment such as x-ray, MRImagnetic resonance imagingmag-NET-ik REZ-uh-nunts IM-uh-jingAn imaging test that uses a strong magnet and radio waves to make detailed pictures of the inside of the body.Full entry Close, CTcomputed tomographykum-PYOO-tid toh-MOG-ruh-feeAn imaging test that uses x-rays and a computer to make cross-section pictures of the inside of the body.tom/o cut, slice-graphy process of recordingFull entry Close and fluoroscopyfluoroscopyfloo-ROS-kuh-peeAn x-ray method that shows moving pictures of the inside of the body in real time.fluor/o glowing (from the fluorescent screen)-scopy looking, viewingFull entry Close, and digital cameras whose pictures appear on monitors during the case. Many modern surgical light systems can show the field on high-definition screens built with the same technology as computer monitors.
• Robots and navigation: robotic surgical systems and computer-guided surgery.
• Tracking: computers follow supplies, instruments and equipment through reprocessingreprocessingree-PROS-es-ingThe steps that make a used reusable medical device safe to use on the next patient.Full entry Close, keep sterile processing's inventory and sterilizationsterilizationstair-uh-luh-ZAY-shunA process that destroys all microorganisms, including spores, on an item; also a permanent birth control procedure.Full entry Close records, and hold the instrument lists used to assemble trays.
• Devices that feed the record: lab programs, glucose monitors, pulse oximeters and even systems that track patients through the hospital send their data to the electronic record.

A frozen section report shows why the way a result reaches the room matters. The pathologypathologypuh-THOL-uh-jeeThe study of disease and its causes and effects, or the disease changes found in a person or tissue.path/o disease-logy study ofFull entry Close department can send it straight to the computer in the OR for the surgeon to read. It is not read out loud, because a patient who is awake under local anesthesialocal anesthesiaLOH-kul an-es-THEE-zhuhNumbing medicine applied to or injected into one small area, so a procedure there is not felt while the person stays awake.Full entry Close could hear bad news before the surgeon has a chance to talk with them and their family.

In an integrated operating room, the room's devices are controlled from one place, by a sterile remote or by voice, and a nonsterile workstation gives the team a computer for documentation and the patient's records (chapter 17).

Computers also come to the point of care: computers on wheels, tablets and smartphones linked by wireless networks pass data in real time.

Newer technology keeps arriving. With telesurgery, a surgeon at a distant site operates on a patient in real time through a robot. Artificial intelligence lets a robot or another computer system do tasks that usually need human intelligence. Chapter 21 teaches robotic surgery.

One system with many parts

A hospital's information system is many systems working together. Many of them are integrated, or interfaced: they pass data to each other electronically, so a piece of information is entered once. That saves repeated typing and lowers the chance of wrong or conflicting data.

Here is integration at work: a pick list for a case cart may print from the OR scheduling system, while the catalog numbers and bin locations on it come from the materials management system. Electronic records do not always connect so smoothly. Interoperability is the ability of different systems to exchange and use each other's data, and not every record system has it.

3The parts of a computer

Hardware

Hardware is the computer's physical parts: the central unit, with the wiring and circuits that run the computer and store its data, and the peripherals, the equipment that works with it, such as the screen, the keyboard and the mouse.

Devices that put information in are input devices: the keyboard, the mouse (or a touch pad or touch screen on a laptop), and the scanner, which turns printed text or pictures into digital form. In the OR and sterile processing, handheld bar-code scanners are input devices too.

Devices that put information out are output devices: the monitor, also called the screen or display, the printer and the speakers. Output reproduced on paper or on a disc is called a hard copy.

Software

Software is the programs that control what a computer can do. A computer works by reading instructions that tell it what to do and how, and it needs them for every task. Some software runs the computer and its hardware, and other software is the programs you use, such as word processing, email and Internet access.

When you switch the computer on, it goes through a start-up process, sometimes called booting. For security, a login screen may ask for your username and password, and when users change, the new user logs in again through that screen.

The instructions themselves are a code of billions of on-off switches. Each switch is a bit, and a block of eight bits is a byte. A byte holds one character, such as a letter. A kilobyte is 1,024 bytes, a megabyte 1,024 kilobytes and a gigabyte 1,024 megabytes, though some references count 1,000 at each step.

Applications and document processing

The programs you will use most at work:

• Word processing creates documents, such as a report or a policy. Save often, use print preview to see the page before you print it, and proofread. A spell checker cannot catch a word that is spelled right but is the wrong word, such as "patience" for "patients".
• Email is part of the internal network in most organizations, and new employees are taught how to use it. Any email can be stored and found again later, and it can be used as a legal document, so write it with care and keep every patient's information confidential. Chapter 16 teaches the manners of a professional email.
• A web browser opens pages on the Internet. Clicking a link, an underlined or bold word or an icon, takes you to another page.
• Clinical programs: the electronic record, the surgery schedule, electronic preference cards and tracking systems. Each facility's programs look a little different, and every staff member has to learn the facility's own systems.

4Networks, the intranet and the Internet

A computer network is two or more computers connected electronically so they can pass information from one to another. A hospital's computers are linked through servers into one network.

The Internet is a vast network that links computers around the world through millions of servers. The World Wide Web is one part of it: a way to exchange files, documents, pictures and other information through the Internet.

An intranet links the computers inside one facility or organization, and it carries messages only within that system. A hospital's intranet holds medical references, articles and announcements, and most important, the facility's policies and safety protocols, so every staff member can look up the current rule. Email is usually part of it too. You reach the intranet with your password, and you log off when you finish, so nobody else can get at what you entered.

Some systems keep their data on servers run by the software company and reached through the Internet. This is called cloud computing.

Finding information you can trust

Anyone can post almost anything on the Internet, true or not, so you choose your sources with care.

• Start from a professional source. For research on a disease or a practice, go first to an organization such as the CDC, a professional association or an academic institution, and search there.
• Read the address before you click. An address ending in .edu is usually an educational institution, .org a nonprofit organization, .gov a government agency, and .com a company, usually with something to sell.
• Search with a few exact words. A search engine looks for the words you type. Keep it to one word or a short phrase, and put quotation marks around a phrase to find only those exact words, such as "laparoscopiclaparoscopiclap-uh-roh-SKOP-ikDone through a few small cuts in the abdomen with a thin camera and long instruments, instead of one large opening.lapar/o abdomen-scopic viewingFull entry Close cholecystectomycholecystectomykoh-luh-sis-TEK-tuh-meeSurgery to remove the gallbladder.chol/e bilecyst/o sac, bladder-ectomy surgical removalFull entry Close".

Keeping the network safe

A firewall, made of hardware and software, protects the facility's network from outside hackers, damage and theft or misuse of information. Antivirus and spyware-detection software add more protection.

You protect it too. Opening a suspicious attachmentattachmentuh-TACH-mentThe deep emotional bond between an infant and a parent or caregiver.Full entry Close or clicking an unreliable link can let malware into a mobile device or an OR computer and expose patient data, which is why AST recommends yearly education on these unsafe habits.

5The electronic record

EMR and EHR

The patient's medical record is the sum of all their encounters with the health care system, and it may be kept on paper or electronically. Most hospitals now keep it in a computer. Using computers and information to manage data, communicate and support decisions in care is called informaticsinformaticsin-fer-MAT-iksThe use of information technology and data to support health care and decisions.informat information-ics the study ofFull entry Close.

You will hear two names for the computer record, and people often use them as if they meant the same thing. Strictly, they differ:

• An electronic medical record (EMR) is the patient's record for one practice, one visit or one hospital stay: in effect, a digital version of a paper chart, used inside that one facility.
• An electronic health record (EHR) is the patient's lifetime record. It links data from every earlier encounter and is meant to move with the patient from provider to provider.

The Core Curriculum uses the term EMR. Whatever your facility calls its system, the rules in this chapter are the same.

What the record holds

An electronic record usually holds:

• a summary of the patient, their history and physical examination, and consults
• the orders, entered through computerized provider order entryCPOEsee-pee-oh-EE (said as letters)Computerized provider order entry: a system in which prescribers enter orders directly into the electronic health record.Full entry Close (CPOE)
• the allergies
• progress notes by the physicians, and the nurses' notes
• lab, radiology and other diagnostic test results
• a graphic record of vital signs, intake and output, and weights
• the medication profile and the medication administration record, the official record of every drug given or held
• the patient's education record, and administrative and billing data

For a surgical patient, it also holds the consents, the operative and anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close records, the count records and the other documents of surgery that chapter 15 lists.

Why records went electronic

Paper records were made one visit at a time. A provider could not easily see the last record, so key facts such as allergies, current medications and earlier complications could be lost between one stay and the next, and that put patients at risk.

An electronic record links all of a patient's data into one record, however many times they come back. It is expected to keep a problem list, to give authorized users access at any hour, to let several caregivers look at it at once, to support confidentiality and keep an audit trail of who did what, and to link to decision support tools. Computer records also cut transcription errors and improve communication between caregivers.

In the US, federal law pushed the change. The American Recovery and Reinvestment Act of 2009, which includes the HITECH Act, offered Medicare and Medicaid incentives to providers that adopted electronic records and used them in meaningful ways, and a federal report in 2018 found certified systems in 96 percent of nonfederal acute care hospitals.

Patients have a legal right to see and get copies of their own records, paper or electronic (chapter 15).

Help, and hazards, on the screen

The record does more than store notes.

• Decision support. A clinical decision support system compares what is entered with rules and warns the user, for example by flagging a patient's allergy before a drug is ordered. Respond to an alert; never just click past it.
• Order entry. With CPOE, prescribers enter orders directly into the computer. The orders are legible, the system can check them for allergies, doses and drug interactionsdrug interactiondrug in-ter-AK-shunA change in how a drug works when it is taken with another drug, a food, a drink or a supplement.Full entry Close, and each order goes straight to the pharmacy and on to the medication administration record.
• Copied and imported data. Some systems carry allergy and medication lists over from an earlier visit, or copy an earlier assessment forward. Check that information for accuracy and update it, so the record shows the patient as they are today.
• Small screens. A record built for a desktop computer can display poorly on a smartphone, and information that is scrolled out of view can be missed.

The record is also only one way the team shares information. A written or electronic record is not enough on its own to carry what the team needs to know about a surgical patient; the briefing, a thorough time-outtime-outTYM-owtA pause just before a procedure when the whole team confirms the right client, procedure and site; also, a short break to calm a child.Full entry Close and the handoffhandoff reportHAND-off ree-PORTThe passing of information and responsibility for a client's care from one nurse or team to another.Full entry Close add what the record cannot.

6Digital documentation

Who charts what in surgery

Each member of the team records their own part of the patient's care, and on a computer that happens in real time, as the case goes on.

Your part as the surgical technologistsurgical technologistSUR-jih-kul tek-NOL-uh-jistA member of the operating room team who prepares the sterile field and instruments and hands them to the surgeon.Full entry Close:

• The counts. Counts are recorded in the intraoperative record: the type of count, the number of each item, the names and titles of the people who counted, the result, the steps taken to resolve a wrong count, and why any count was not done. You sign next to the counts with your credentials.
• The drugs on the field. The circulator records every medication delivered to the sterile field, and at the end you give the circulator the final total of each medication and solution used, to record.
• Identification and the site. Where the facility's policy allows, a CSTCSTsee-es-tee (said as letters)Certified Surgical Technologist, a credential for surgical technologists; in maternity care, contraction stress test.Full entry Close can complete the part of the intraoperative record on correct patient identification, site and procedure.

Machines document too: a sterilizersterilizerSTAIR-uh-ly-zerA machine that kills all germs, including spores, on instruments and supplies.Full entry Close records the time, temperature and pressure of every cycle on a printout or digitally, and the record is kept as long as the state's statute of limitations requires (chapter 27 teaches how it is checked).

Rules for electronic entries

The legal rules for every record are in chapter 15. A computer adds a few of its own.

• Chart on time. Document accurately and promptly after the care, never ahead of it, and record changes as they happen instead of at the end of the shift.
• Chart only your own work, under your own login. Accountabilityaccountabilityuh-kown-tuh-BIL-ih-teeBeing answerable for your own decisions, actions and the results of the care you give or hand to others.Full entry Close for an entry rests with the person who made it. Your password links every entry to you, so an entry made under your login is yours. Never document for someone else.
• Never chart what was not done. Recording an assessment, a treatment or a drug as done when it was not is falsification, with serious legal consequences for you and the facility.
• Correct errors the system's way. An electronic entry made in error is corrected with the details of the error, and the system keeps the correction in the background. Most electronic records keep a log of every edit, so any change can be seen later.
• Use the templates. Many systems guide each entry with templates or checklists, which keep documentation consistent and complete.
• Never leave a screen open. Do not walk away from a computer while you are logged in; log out when you leave.

7Scheduling and the schedule board

Surgery is booked through a scheduling office with a computer program. When a procedure is scheduled, authorized staff assignassignuh-SINETo give a staff member the care of a client, or tasks that are already part of that person's usual job and allowed by their license.Full entry Close the surgeon's preference card to it, and that creates the pick list, the list sterile processing uses to load the case cart.

Cases are usually assigned to the nurses and technologists the day before, with emergencies added as needed. In most facilities the assignments go up on a schedule board near the entrance to the restricted area, as a whiteboard or a digital screen, and many ORs also print the schedule for each staff member. The board lists:

• the patient's initials, never a name or other identifier
• the procedure and the room
• the surgeon and the anesthesia provideranesthesia provideran-us-THEE-zhuh pruh-VY-derThe licensed professional who gives anesthesia and watches over the client's breathing and vital functions during a procedure.Full entry Close
• the circulator and the scrub
• sometimes, the type of anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close planned

Check the master schedule during the day, because cases are canceled, moved up and postponed. Chapter 28 shows how you plan your day from it.

The schedule feeds other systems too. When the OR's scheduling system is linked to sterile processing's tracking system, sterile processing can see what instruments, supplies and equipment each case needs, in real time or close to it.

The board is posted near the entrance to the restricted area, so what it shows is a privacy question. Removing patient identifiers from it is one of the Core Curriculum's four rules for protecting a patient's information (see Keeping patient information safe, below).

8Electronic preference cards

A surgeon's preference card lists what one surgeon uses for one procedure, and it may be an electronic document or a paper one. Chapter 28 teaches what goes on the card and how you use it to pull a case.

Cards used to be handwritten, with notes scribbled in the margins, and they often became hard to read. If the surgeon worked at more than one hospital, copies were hard to get, and if the surgeon moved, the cards stayed behind. Now most facilities build and keep their cards electronically. An electronic card is easier to update, gives an accurate copy when you prepare for a case, and can be sent to another facility.

An electronic card is one part of the software used in surgery, and it is linked to the rest of the system:

• the schedule: each scheduled case is given its card, and the card produces the pick list
• billing, so the supplies used are charged to the patient
• inventory, because sterile processing's supply information feeds the card

Managing cards electronically can make the work more efficient, cut costs, control inventory and make charging easier. Cards can even be read on mobile devices.

Any card can go out of date or be wrong, and every case cart is built from it, so keeping cards current is critical; chapter 28 teaches how you check a card and get a wrong one corrected.

9Bar codes and RFID

Many of the safety systems in this chapter rest on two ways of letting a computer recognize an object: the bar code and the radiofrequency tag.

A bar code is a label a computer can read: scanning it lets the system trace the item. On a drug, it ties the vial to its product code, expiration date, manufacturing number and quantity, so the computer can confirm the drug is what its label says and is not counterfeit. A one-dimensional bar code is the familiar row of lines, used on wrapped instrument sets and peel packs. A two-dimensional data-matrix code is a small pattern of dots that can be etched by laser onto a single instrument or stuck on as a dot label.

Radiofrequency identification (RFID) uses a small tag, or transponder, that answers a radio signal. A system has three parts: the tag, a reader, and database software that records what the reader finds. Because the reader picks up the tag's signal, RFID can show where an item is in real time as it moves through the facility.

Each has strengths:

• Bar codes are generally used to track sterile surgical trays and instruments. A bar code must be in the scanner's line of sight, so the person scanning has to look at the package, and that look is also a check of the package's sterile integrity. That is one reason bar codes are likely to stay in use beside RFID.
• RFID can give an item's location in real time, read by fixed receivers around the building. Tags that survive sterilizationsterilizationstair-uh-luh-ZAY-shunA process that destroys all microorganisms, including spores, on an item; also a permanent birth control procedure.Full entry Close are a newer development and can be costly, so RFID is generally used for patient care equipment that is never sterilized.
• Both wear out. Chemicals can fade bar code labels and laser etchings until a scanner cannot read them, steam heat can damage RFID tags, and cleaning can loosen the glue that holds tags on.

Implants have their own record, a permanent implant log kept electronically or in writing, and the FDA requires certain implanted devices to be tracked so the maker can find them in a recall. Chapter 29 teaches how you get each implant's details to the record.

10Instrument tracking

Instruments and equipment move constantly between departments as they are used, processed and sent out again. Sterile processing tracks each item so it can be found quickly, so supplies are replaced on time, so its use is known, so the records of sterilizationsterilizationstair-uh-luh-ZAY-shunA process that destroys all microorganisms, including spores, on an item; also a permanent birth control procedure.Full entry Close and distribution are kept, and for quality, regulation and cost.

Bar code scanning lets sterile processing follow specific instrument sets and find where each one is at any time. Tracking can work at two levels:

• Set level: a bar code on the wrapped set or peel pack tells staff where it was last scanned.
• Instrument level: a data-matrix code on each instrument shows which set it went into. That keeps the right instruments with the right set, and it can find costly devices, such as powered, endoscopicendoscopicen-doh-SKOP-ikDone with an endoscope, a thin tube with a light and camera passed into the body.endo- within-scopic viewingFull entry Close or robotic instruments, when they are due for maintenance.

Scanning happens with handheld wireless scanners, scanners wired to a computer terminal, fixed receivers that read RFID tags around the building, or by typing information in by hand.

A tracking system can record:

• the complete tray list used to assemble the set, with the catalog numbers, the quantity of each instrument, the technician who assembled and inspected it, the date it was processed and the sterilization method
• any instrument missing from the set, so it can be noted on the outside of the set
• the last known location of each set, the number of processing and use cycles it has been through, and its repairs and preventive maintenance
• sets that have been used a set number of times, flagged for routine work such as sharpening the scissors
• sterilization load quarantines and recalls
• which trays and instruments were used on each patient, linked to that patient's record

That last link is a patient safety tool. If a patient is later suspected or found to have a prion disease such as Creutzfeldt-Jakob disease, tracking each instrument helps show which instruments were used on that patient and how they were processed and sent out afterward.

The system is only a tool, though. Computers are one part of the whole information system, and the sterile processing professionals who scan, inspect and assemble every set are the key to safe, high-quality care. Chapter 27 teaches tracking as a step of sterile processing.

11Technology for counts

An object left in a patient by accident after surgery or another invasive procedure is a sentinel eventsentinel eventSEN-tih-nul ee-VENTAn unexpected event in health care that causes a client's death, permanent harm or severe temporary harm.Full entry Close, and the sponge is the item retained most often. The count is the main defense, but it is not perfect: reports have found that more than 80 percent of retained sponges were left when the sponge count was recorded as correct. Counting by hand alone has not been enough, and the evidence supports technology as an addition to it.

Three sponge-tracking technologies add to the count:

• Numbered sponges: each sponge carries its own number, so the team accounts for each one instead of a total, and a missing one is easier to notice.
• Bar-coded sponges: each sponge, and in some systems each instrument, has a unique code. It is scanned in at the start of the case and scanned again at the end, much like scanning at a grocery checkout, and the system prints a record of the counts.
• Radiofrequency sponges: a small chip is built into each sponge. At key points in the case, a team member passes a handheld wand over the patient; if a sponge is still inside, the wand senses its chip, the screen shows it and an audible alarm sounds. Newer systems can find instruments too.

The results can be large. In one hospital's study, adding a radiofrequency system to the manual counts was linked with 68 percent fewer reports of near missesnear missNEER MISAn error or unsafe situation that was caught before it reached the client, so no harm was done.Full entry Close and unresolved miscounts. The American College of Surgeons recommends x-ray-detectable, or radiopaqueradiopaqueray-dee-oh-PAYKBlocking x-rays, so the material shows up white on an x-ray image.radi/o radiation, x-rayopaque not letting throughFull entry Close, items in the wound and, when indicated, an x-ray or another technology, such as bar coding or radiofrequency detection, to make sure no item is left behind. These devices are gaining approval and may become required.

12Medication tracking

Drugs pass through several computer systems on their way to the patient, and each one is built to make a medication error less likely.

• Order entry. The prescriber enters the order through CPOECPOEsee-pee-oh-EE (said as letters)Computerized provider order entry: a system in which prescribers enter orders directly into the electronic health record.Full entry Close. It goes to the pharmacy and on to the patient's medication administration record.
• Automated dispensing cabinets. Computer-controlled cabinets are often used to hand out drugs in surgery. A bar code scan, or the user's own access code, lets an approved user reach the drugs ordered for a particular patient, and when the cabinet is linked to the record, the drug and the person who took it are linked to that patient's record.
• Bar code medication administration (BCMA). Before a drug is given, the patient's wristband and the drug's label are scanned. The system checks the rights of medication administration: that the right patient is getting the right drug in the right dose at the right time, and it warns of an allergy, a vital sign to check first, or a drug that needs a second nurse to verify it. The scan also records the dose in the medication administration record.
• Smart pumps. A smart infusion pumpinfusion pumpin-FYOO-zhun PUMPA machine that delivers IV fluid or medicine into the body at a set rate and amount.Full entry Close has a drug library with each drug's usual concentrations, doses and limits, and it warns when a dose is past a set limit. Linked to the record, it can receive the order's settings after the drug is scanned and send back what was infused.

These systems help. One report linked bar-code medication administration with a 41 percent drop in medication errors and a 51 percent drop in possible adverse drug reactionsadverse effectad-VERS ih-FEKTAn unwanted and harmful effect of a drug or treatment given at a normal dose.advers/o against, turned againstFull entry Close. But errors still happen, and bar-code administration can be hard to put in place during surgery. In the OR, many drugs pass from the circulator to the scrub, who prepares them on the sterile fieldsterile fieldSTAIR-ul feeldAn area set up with sterile drapes and supplies, kept free of all germs, for a sterile procedure.Full entry Close and hands them to the surgeon to give.

On the field, the surgical technologistsurgical technologistSUR-jih-kul tek-NOL-uh-jistA member of the operating room team who prepares the sterile field and instruments and hands them to the surgeon.Full entry Close is part of the drug-handling chain and shares responsibility for any drug error, whether or not the patient is harmed. The circulator records every drug delivered to the field, and you report the totals used at the end. Chapter 12 teaches the six rights and how drugs are passed, labeled and handled on the field.

13Patient identification and transport

Technology helps identify the patient too. The Joint CommissionThe Joint Commissionthuh JOYNT kuh-MISH-unAn independent US organization that inspects and accredits hospitals and other health care organizations against safety and quality standards.Full entry Close requires at least two patient identifiers whenever care is given, such as the name and date of birth, never the room number or location, because patients move from room to room. An electronic identifier, such as a bar code or RFID tag, counts when it holds two or more identifiers specific to that person.

An identification markermarkerMAR-kerSomething that can be measured, such as a substance in the blood, that shows a disease or body process is present.Full entry Close on every surgical patient helps prevent wrong-patient, wrong-procedure and wrong-site surgery. It may be a plain wristband, a wristband with a unique bar-coded identifier, or an RFID marker.

Wristbands have not ended misidentification, so you still follow every other identification policy. Watch for the common wristband errors:

• no wristband
• another patient's wristband
• more than one wristband, with conflicting information
• missing, wrong or unreadable information
• a patient whose name is spelled or sounds the same, or nearly the same, as another patient's

Some facilities use a scan or imprint card: the patient's identification card processes the paperwork and matches the identification band. That card stays firmly attached to the chart during transport and stays with the chart until the patient returns to their unit, and the chart goes wherever the patient goes.

When you transport a patient, identify them first, much as in a time-outtime-outTYM-owtA pause just before a procedure when the whole team confirms the right client, procedure and site; also, a short break to calm a child.Full entry Close: the patient states their name, and you check it against the name band, the chart and the surgery schedule. Chapter 28 teaches identification and the time-out, and chapter 31 transport and transfer.

14Verification

The scanners, alerts and tracking systems in this chapter are extra checks, and none of them replaces your own.

• A machine can be wrong. Never assume the electronic system handed you the right drug: read the label every time (chapter 12 explains how a dispensing cabinet can give the wrong one).
• No shortcuts. Follow your facility's policy for every scan, avoid shortcuts with bar coding and the other technologies, and keep interruptions to a minimum while drugs are prepared and given.
• You stay responsible. The person giving a drug is responsible for any error even when a smart pump and the record set it up, so keep a questioning mind.
• Look as you scan. A bar code scan is also a moment to inspect the package and its sterile integrity.
• Technology is an extra check. Count technology works on top of the manual count, and a wristband on top of asking the patient.
• Stop when they disagree. If the screen, the label, the wristband or the patient do not match, stop. No patient is moved, and no procedure or drug goes ahead, until the difference is resolved.

15Keeping patient information safe

Chapter 15 teaches the law: HIPAA's Privacy Rule, what counts as protected health information (PHI), the minimum necessary standard, and the Security Rule that protects the electronic part. This section is about the safeguards you practice inside the computer systems you use every day, because protecting PHI is the job of everyone who works in health care.

The Core Curriculum names four habits, and each one closes a door.

1. Open only what you need

Only the team members directly involved in a patient's care have a legitimate reason to open that patient's record, and then only for the information their job needs. Most staff can reach only the patients in their own work area.

• Never look up someone you know. If a neighbor, a coworker or a family member is admitted, do not open their record unless you are caring for them.
• Every look is recorded. The system logs who opened each record and when, and the facility can trace everything you open. Looking at a record you have no need for is unethical, and it leads to discipline and can cost you your job or your place in school.
• As a student, read the record only for what you need to care for your patient, keep your notes free of patient identifiers, and stop opening a patient's record once your clinical shift with them is over.

2. Keep your login to yourself

Your password is given to you when you are hired, and it links you to every entry you make and every record you open. Nobody else has the right to use it to reach patient information.

• Never share it, with anyone, for any reason, even a temporary staff member who has not been given a login yet.
• Make it strong: a mix of letters, numbers and symbols that is hard to guess, changed as often as your facility requires.
• Systems lock out guessers. A device can be set to lock after a number of wrong passwords.

3. Log out every time

When you leave a computer, log off, or lock it with your password, so nobody can use your access after you walk away. Never leave a screen unattended while you are logged in, not even to step away for a minute.

• The system helps. An automatic sign-off logs a user off after a set time without activity.
• Mind the screen. Make sure no one who should not see it can read the screen. Computers can sit in restricted areas, and privacy filters can hide a screen that visitors pass.

4. Keep identifiers off the boards

The schedule board shows the patient's initials, never a name or other identifier.

• Printouts are PHI. A printed schedule or work list holds protected information, so never leave it where others can see it, and shred it or put it in a locked shredding bin when you are done. Never print from the record for personal use, or carry patient information out of the facility.
• Files are PHI too. Computer files that hold surgery schedules and other daily records with PHI are deleted according to your facility's policy.
• Screens on view. Patients and visitors may not take photos that show medical devices displaying patient data.

16Phones, tablets and photos in the OR

Smartphones, tablets and other mobile devices can do almost everything a computer can: take photos, send and receive files, and share information in an instant. Used for care, they bring patient data, drug information and preference cards to the point of care. Used for anything else, they distract. A team member looking at a screen instead of the patient can miss signs of a change in the patient's condition, or of an emergency such as a cardiac arrestcardiac arrestKAR-dee-ak uh-RESTThe sudden stop of the heart's pumping, so blood no longer reaches the brain and body.Full entry Close.

AST's guideline for mobile devices in the OR sets these rules:

• Clean it before it comes in. Phones carry germs: in studies, more than 90 percent of health care workers' phones grew bacteria, MRSAMRSAMUR-suh, or said as lettersMethicillin-resistant Staphylococcus aureus, a staph bacterium that many common antibiotics cannot kill.Full entry Close among them. Clean and disinfectdisinfectiondis-in-FEK-shunCleaning a surface or object with chemicals or heat to kill most germs, though not always all bacterial spores.Full entry Close a device before it enters the surgery department, PACU or preoperative holding, with a wipe the maker approves so the screen is not damaged, and clean your hands before and after you use it. The OR's computers are wiped down routinely too (chapter 30).
• Personal phones stay outside. Use a personal device only in the areas set aside for it, such as the break room. Never use a phone during the patient's care, even through a wireless headset, and never use the OR computer for personal browsing or social media.
• Silence it. A ring tone or a buzz breaks the team's communication, can be mistaken for an equipment alarm, and can startle a patient who is awake or just going to sleep, when hearing is the patient's strongest sense.
• Keep it away from life support. A phone's signal can interfere with medical equipment and make it show a wrong value or set off an alarm. Turn devices off near critical care and life support equipment, and use them only 1 meter (about 3 feet) or more away from medical equipment.

Patient information never goes by ordinary text message. A plain text cannot prove who sent it and leaves no original copy to back up what goes into the record, and it is not secure. Send patient information only through the secure messaging system your facility provides.

Photos and patient data on devices

A device that can take photos or video is not used in the presence of a surgical patient at any point in their care. Never post PHI, photos or videos of a surgical patient on social media, blogs or discussion boards, and never send them by email or text. Chapter 15 teaches why even a photo without a face can identify a patient.

When the facility allows devices for work:

• PHI is saved only on the facility's approved, secure servers or on encrypted devices.
• The device is password-protected, locks after a number of wrong passwords, and logs off by itself after it sits idle.
• The facility may require the right to wipe its data from a lost or stolen device, which also erases your own data.

Breaking these rules can cost you your job, your certificationcertificationser-tih-fih-KAY-shunA credential from a professional organization showing that a person has met the standards for a specialty.Full entry Close and your license, and can bring legal action. That is why AST recommends that surgery departments give their staff HIPAA and device training every year.

17Alarms and alerts

The equipment around an anesthetized patient talks to the team through alarms. An alarm is an automatic warning set off when a measurement moves outside its normal range, telling the team there may be a problem with the patient's physiology or with the device itself.

So many devices sound so many alarms that teams can stop hearing them. In one study of 25 heart operations, the patient monitor and anesthesiaanesthesiaan-us-THEE-zhuhLoss of feeling or sensation, often brought on by drugs so that surgery or a procedure can be done without pain.an- withoutesthesi/o feeling, sensation-ia conditionFull entry Close workstation sounded 1.2 alarms a minute, and 80 percent of them needed no treatment. Hearing frequent alarms that mean nothing makes people slow to respond, or deaf to the one that matters. This is alarm fatigue. A Joint CommissionThe Joint Commissionthuh JOYNT kuh-MISH-unAn independent US organization that inspects and accredits hospitals and other health care organizations against safety and quality standards.Full entry Close search of the FDA's device reports found 566 patient deaths linked to alarms from January 2005 to June 2010, and ECRI named alarm hazards the top health technology hazard of 2015.

Some alarms are false, or nuisance alarms: an alarm set off by something that needs no treatment, such as the patient moving or a sensor being handled. Poorly placed electrodes and damaged cables cause false alarms too, so cords and cables are checked for damage. Alarms also come thick and fast during the inductioninductionin-DUK-shunThe starting of a process on purpose, such as bringing on labor or putting a client under anesthesia.Full entry Close of anesthesia and emergence from it, when the patient's circulation and breathing change quickly, so the team stays alert to the real ones through those busy minutes.

The Joint Commission requires every hospital to improve the safety of its clinical alarm systems: to identify the alarm signals that matter most and to set policies on alarm settings, on when an alarm may be turned off or changed, and on who has the authority to do it. Alarms should be turned off only briefly and in rare circumstances, and when one is silenced, the record shows who silenced it, when and why.

Your part:

• Be another pair of eyes and ears. Most alarm devices are run by the anesthesia provideranesthesia provideran-us-THEE-zhuh pruh-VY-derThe licensed professional who gives anesthesia and watches over the client's breathing and vital functions during a procedure.Full entry Close, but you can serve the patient by knowing them too.
• Know the sounds. Learn the purpose of each alarm-equipped device in your rooms and the sound of its alarm, and learn the alarms of new equipment, which may differ from the old.
• Tell the right person. When an alarm sounds, tell the team member who manages that device that there may be a problem with the patient or the equipment. Never ignore an alarm because it "always goes off"; who may silence or change an alarm is set by your facility's policy.

Screens raise alerts too. The record warns of allergies and conflicting orders, bar-code scanning confirms the patient and the drug and flags an allergy or a check still to be done, and a smart pump warns of a dose past its limit or a blocked line. Treat every alert as a question that needs an answer. Chapter 23 teaches the alarms on the room's equipment, such as the electrosurgical unitelectrosurgeryee-LEK-troh-SUR-jer-eeUsing high-frequency electric current through a handheld tool to cut tissue or seal bleeding vessels during surgery.Full entry Close and the tourniquet, and chapter 13 the anesthesia monitors.

Check yourself5 quick questions

Free for everyone. Pick an answer for each, then check them all at once.

In the ORWhere you'll use this