TeamSTEPPS® Instructor Manual: Specialty Scenarios

OR

Specialty scenario for this guide.

Contents

Scenario 67
Scenario 68
Scenario 69
Scenario 70
Scenario 71
Scenario 72
Scenario 73
Scenario 74
Scenario 75
Scenario 76
Scenario 77
Scenario 78
Scenario 79
Scenario 80
Scenario 81
Scenario 82
Scenario 83
Scenario 84


Scenario 67

 
Appropriate for: All Specialties
Setting: Hospital

 

A 63-year-old woman is undergoing cataract surgery. The surgeon calls for the lens, and the circulating nurse, just returning from lunch, presents what he thinks is the correct lens. Without looking at the small count sheet, the surgeon asks the nurse to open the lens container. The lens he inserts turns out to be the lens intended for the next patient of the day. This error is discovered by the circulator immediately after the lens is inserted, and he promptly informs the surgeon.

Instructor Comments

  • This scenario demonstrates the potential results of failing to conduct a handoff and check-back. In this case, the nurse returning from lunch should have received a handoff and a check-back on the accuracy of the lens.

Skills Needed

  • Communication.

Potential Tools

  • Handoff, Check-back.

Return to Contents


Scenario 68

 
Appropriate for: All Specialties
Setting: Hospital

 

Mr. Smith, a 65-year-old male, is scheduled for a major surgical procedure at 1230 the next day. Helen, the nurse coordinator, identifies an open room for the following day and moves Mr. Smith's case from 1230 to 0730 but does not check with the office of the surgeon, Dr. West. The next morning, Dr. West is paged, and the patient is brought into the room. Dr. West then calls into the room from a different hospital, "I'm in the OR across town all morning, that's why this case is not scheduled to start until the afternoon." The patient is taken back to his room and is told what has happened.

Instructor Comments

  • The information that should have been passed along to everyone in the unit was that Dr. West would not be able to operate until later that day. However, the means of exchanging this information failed, and there was no check-back performed before bringing the patient into the room.

Skills Needed

  • Communication. Situation awareness.

Potential Tools

  • Handoff, Check-back.

Return to Contents


Scenario 69

 
Appropriate for: All Specialties
Setting: Hospital

 

A 35-year-old male is scheduled for a right ankle arthroscopy. The patient arrives in the hold area about 2 hours prior to surgery. The perioperative nurse performs patient verification, including identity verification with the chart, ID band, and verbally with the patient. The procedure and site are verified verbally with the patient, the consent form, physician orders, and history and physical examination. Three previous ankle surgeries were performed that day on the left ankles of other patients, but this procedure is scheduled for the right ankle. An emergency requiring the orthopedic room arises that must be addressed immediately, thus postponing the ankle arthroscopy. Because of the delay, the surgeon leaves the operating room understanding he will be contacted when the emergency surgery is complete and the ankle arthroscopy can proceed.

The emergency turns out not to be an emergency; plans are made to proceed immediately with the orthopedic case. The patient is taken to the operating room and induced by an anesthesia provider. The O.R. circulating nurse places a tourniquet on the left thigh. The staff and resident orthopedic surgeons arrive and perform a final adjustment of the tourniquet and patient positioning, and inject the ankle with a local anesthetic. An arthroscopy of the left ankle is performed, and the patient is sent to the Post Anesthesia Care Unit. Upon awakening, the patient asks why surgery was performed on his left ankle when he had consented to surgery on his right ankle. The surgeon is notified. Surgery for the correct ankle is performed at a later date.

Instructor Comments

  • The lack of check-back or crosscheck by the circulating nurse and surgeon leads to a procedure being performed on the wrong ankle. Each provider has an inherent role for patient advocacy and an obligation to perform redundant checks whenever laterality is a potential issue.

Skills Needed

  • Communication. Mutual support.

Potential Tools

  • Check-back, Handoff, Advocacy/assertion.

Return to Contents


Scenario 70

 
Appropriate for: All Specialties
Setting: Hospital

 

A staff nurse, technician, and anesthesiologist are providing care for elective surgical cases. The team is collaborating with the surgeon on ways to minimize between-case delays. The next patient is in the preoperative area and has been seen by the Operating Room (OR) nurse. The anesthesiologist knows he has to complete the present case, deliver the patient to the Post-Anesthesia Care Unit (PACU), and process the next patient, including starting the intravenous (IV) catheter. The OR nurse asks the anesthesiologist if he wants her or the technologist to start the IV catheter. The anesthesiologist initially declines, but the nurse suggests that the technician is becoming proficient in IV placement and enjoys perfecting the skill. The anesthesiologist delegates the catheterization of the next patient to the technician while he takes the current patient to the PACU.

Instructor Comments

  • This case represents an example of mutual support by using a Two-Challenge rule to improve collaboration by effective delegation. By not accepting the initial refusal, the nurse convinces the physician to delegate the less critical task, thus allowing the physician to use his time for the most critical task. The outcome is improvement in overall efficiency, and development of a shared mental model.

Skills Needed

  • Mutual support. Situation awareness. Shared mental model.

Potential Tools

  • Two-Challenge rule, Collaboration, Prioritization, Delegation, Task assistance.

Return to Contents


Scenario 71

 
Appropriate for: OR
Setting: Hospital

 

Three C-Arm machines are dedicated to the Operating Room (OR). Two are being used for orthopedic cases, and one for a cholecystectomy with an intraoperative cholangiogram. An urgent neurological case is scheduled and shortly after that a pediatric emergency, both requiring a C-Arm. The addition of these two cases results in the need for five C-Arms at once. The nurse coordinator contacts the Orthopedic and Pain Management Clinics to ask whether their machines are currently in use, and if not, whether they could be used in the OR. Neither site is currently using its C-Arm, and the machines are moved to the OR. The two additional cases proceed in a timely manner.

Instructor Comments

  • This scenario illustrates the potential risks of not managing your resources properly. In this case, some equipment has high usage demands and becomes scarce throughout the unit. Through situation awareness and providing mutual support, the nurse is able to prioritize resources and resolve potential conflict.

Skills Needed

  • Mutual support. Situation awareness.

Potential Tools

  • Prioritization, Task assistance, Collaboration.

Return to Contents


Scenario 72

 
Appropriate for: OR
Setting: Hospital

 

After the elective Operating Room (OR) schedule is completed, the senior surgical technologist, Frank, receives three instrument sets from a company representative who states, "These need to be processed tonight for the first case in room 18 tomorrow." "I'll take care of it," states Frank. Frank puts the sets aside and returns to his routine administrative duties. At 2200, two emergency trauma cases arrive. Frank and the rest of the team go into action and finish both cases at 0715. A core team member from room 18 calls for the specialty gear and is told that it has not been processed and is unsterile. The case is delayed for 30 minutes while the equipment is properly processed.

Instructor Comments

  • This scenario demonstrates how managing resources can prevent inefficiency or potential injury. Had Frank promptly prepared the instruments when they were received, the case requiring the special instruments would not have been delayed.

Skills Needed

  • Mutual support.

Potential Tools

  • Prioritization.

Return to Contents


Scenario 73

 
Appropriate for: OR
Setting: Hospital

 

A 30-year-old depressed, chronic pain patient jumps from the hospital roof and sustains severe and multiple life-threatening injuries. She is briefly resuscitated in the Emergency Department. The trauma surgeons request access to the Operating Room (OR) for immediate laparotomy and other repairs. The core OR team begins additional line placement for fluid and blood administration but is quickly overwhelmed with high acuity tasks and complex problem solving. The team asks for additional anesthesia personnel to assist. After the liver laceration is packed off, the orthopedic team applies an external fixator to the pelvis; and a second core team assists with simultaneous lower extremity long bone stabilization to expedite the surgery.

Instructor Comments

  • This scenario demonstrates how to use mutual support to manage resources and create a shared mental model.

Skills Needed

  • Mutual support. Shared mental model.

Potential Tools

  • Prioritization, Task assistance, Collaboration.

Return to Contents


Scenario 74

 
Appropriate for: All Specialties
Setting: Hospital

 

A 24-year-old female with a history of asthma is admitted to the Intensive Care Unit (ICU) with acute bronchospasm. The ICU attending physician intubates the patient and gives orders for bronchodilators, steroids, and ventilation with 100 percent oxygen. Multiple providers are around the bed, including the ICU attending physician, a consultant pulmonologist, two ICU nurses, several technicians, and a respiratory therapist, who is ventilating the patient. The patient appears extremely anxious and has a pulse of 140–150 beats/minute and a pulse oxygen saturation of 90–92 percent. An anesthesiologist, who is delivering another postoperative patient to the ICU, offers to help and assesses the situation. The patient's oxygen saturation progressively decreases to < 80 percent, and the tachycardia is replaced by severe bradycardia < 40 beats/minute. The anesthesiologist moves to the head of the bed and performs a laryngoscopy. She sees that the endotracheal tube is actually in the esophagus. She immediately pulls out the tube, successfully intubates the patient, and then rapidly gives orders for intravenous epinephrine and ventilations with 100 percent oxygen. The anesthesiologist then orders one technician to handle crowd control, one ICU nurse to record, and one ICU nurse for all medication administration. The anesthesiologist warns the team to anticipate, but not be concerned about, an upcoming tachycardia that will rapidly resolve. The patient's pulse oxygen saturation rapidly returns to the high 90s, and the ventilations become progressively easier.

Instructor Comments

  • In this scenario, someone emerges as the situational leader when, through situation awareness, she realizes a potential problem exists, advocates to correct the problem, communicates to develop a shared mental model, and performs a handoff for specific duties.

Skills Needed

  • Team structure. Communication. Situation monitoring. Situation awareness. Shared mental model. Mutual support. Leadership.

Potential Tools

  • Handoff, Cross-monitoring, Prioritization, Advocacy/assertion, Collaboration, Conflict resolution.

Return to Contents


Scenario 75

 
Appropriate for: OR
Setting: Hospital

 

A 36-year-old male undergoes anesthetic induction in preparation for a laparoscopic cholecystectomy. The anesthesia team has tried to intubate the patient three times (once by trainee, twice by staff). The patient develops laryngospasm and is ventilated by hand-bag. He is retaining oxygen saturations > 94 percent. The anesthesia staff has called for the fiberoptic intubation set and is preparing to perform fiberoptic intubation. The surgeon and anesthesia team request another anesthesia provider to assist.

The anesthesiologist walks into the room and is asked by the primary anesthesia team to "stand by" while they perform fiberoptic intubation. The anesthesiologist, concerned about attempting fiberoptic intubation on a patient with upper airway obstruction who required controlled ventilation, requests that she ventilate the patient by hand. Able to confirm that air movement is adequate, although difficult, she orders 10 mg of succinylcholine. The laryngospasm abates, and the patient becomes easier to ventilate. The anesthesiologist assesses that the head/neck could be placed in a more ideal position that might facilitate successful intubation and requests assistance in repositioning. After repositioning, she orders an additional 70 mg of succinylcholine. She then performs the laryngoscopy while instructing the Operating Room nurse to provide firm cricoid pressure and having the anesthesia staff assist with head extension. A laryngeal aperture is created, and the patient is successfully intubated.

Instructor Comments

  • In this scenario, the anesthesiologist uses situation awareness and teamwork and emerges as the situational leader. She uses communication to develop a team structure and shared mental model. She also provides mutual support and prioritizes and delegates actions for Task assistance.

Skills Needed

  • Team structure. Communication. Situation monitoring. Situation awareness. Shared mental model. Mutual support. Leadership.

Potential Tools

  • Cross-monitoring, Prioritization, Delegation, Task assistance, Collaboration.

Return to Contents


Scenario 76

 
Appropriate for: All Specialties
Setting: Hospital

 

While waiting for a surgical patient to awaken from general surgery, the staff anesthesia provider and her resident tend to the patient and discuss different concepts related to anesthesia. The patient seems to be taking longer than expected to awaken. The circulating nurse glances over at the anesthesia machine and notices that the nitrous oxide is still on and informs the anesthesiologist.

Instructor Comments

  • This scenario demonstrates how monitoring the environment can help patient care. This scenario uses situation awareness, shared mental model, and teamwork.

Skills Needed

  • Communication. Situation monitoring: assess status of patient. Situation awareness. Mutual support.

Potential Tools

  • Task assistance, Advocacy/assertion, Collaboration, Cross-monitoring.

Return to Contents


Scenario 77

 
Appropriate for: OR
Setting: Hospital

 

A 56-year-old obese female undergoes general anesthesia induction, and the incision is made for planned complex vertebral surgery. Antibiotics do not accompany the patient to the Operating Room (OR), orders are not in the chart, and the surgeon does not request antibiotics. The anesthesiologist, realizing that antibiotics are normally given in these cases, asks the nurse to check whether any were given on the ward before transfer to the OR. On finding no antibiotics were given, the anesthesiologist asks the surgeon whether antibiotics are indicated. The surgeon does want antibiotic prophylaxis, which is promptly given.

Instructor Comments

  • This scenario provides an example of advocacy/assertion for the patient using situation awareness.

Skills Needed

  • Communication. Situation awareness. Mutual support.

Potential Tools

  • Advocacy/assertion, Collaboration, Cross-monitoring.

Return to Contents


Scenario 78

 
Appropriate for: OR
Setting: Hospital

 

The patient is in the Operating Room, prepped and draped for a left knee arthroscopy. The anesthesia resident is reviewing the preoperative section of the anesthesia record, which indicates the proposed surgery is for a right knee arthroscopy. He asks the surgeon to verify whether the surgery is on the left knee because his record states right knee. The circulating nurse checks the patient's chart, and the surgeon reexamines the x rays. The surgery should be performed on the right knee. The drapes are removed, the correct extremity (right) is prepped and draped, and the surgery completed.

Instructor Comments

  • This scenario demonstrates how situation awareness and patient monitoring can be used successfully to advocate for the patient.

Skills Needed

  • Communication. Situation awareness. Mutual support.

Potential Tools

  • Advocacy/assertion, Collaboration, Cross-monitoring.

Return to Contents


Scenario 79

 
Appropriate for: OR
Setting: Hospital

 

It is a busy day in the Operating Room. Larry is the perioperative team circulating nurse working with Jane as the scrub nurse for a patient who requires an AV vascular graft for dialysis. Larry is providing supplies and assisting the surgeon. The vascular surgeon requests a natural collagen graft. Larry opens the correct size but does not notice a notation on the outside of the package that it is now past the expiration date to safely use the graft. Jane is assisting the vascular surgeon and does not give her full attention to the package when shown by Larry. The expired graft is opened on the back table and used. It is not until the next day that the mistake is discovered.

Instructor Comments

  • This scenario demonstrates how cross-monitoring team members can help prevent error, damage, or injury. Unfortunately, Larry's team members fail to monitor his performance or check-back, which could have prevented the error with the graft.

Skills Needed

  • Communication. Situation awareness.

Potential Tools

  • Check-back, Advocacy/assertion, Collaboration, Task assistance, Cross-monitoring.

Return to Contents


Scenario 80

 
Appropriate for: OR
Setting: Hospital

 

During a particularly long case, both the anesthesia provider and the circulating nurse notice blood loss increasing throughout the case from 150 cc to 800 cc in a half-hour period. The surgeon is made aware and instructs the circulating nurse to contact the blood bank to change the type, screen to a type, cross match and bring the blood to the suite.

Instructor Comments

  • This scenario provides an example of effective monitoring of the patient's status. It demonstrates how team members can use monitoring to assess problems and develop a plan of care.

Skills Needed

  • Communication. Situation monitoring: assess status of patient. Situation awareness. Shared mental model. Mutual support.

Potential Tools

  • Cross-monitoring, Collaboration.

Return to Contents


Scenario 81

 
Appropriate for: OR
Setting: Hospital

 

A spine surgeon spends 10 minutes properly positioning his patient on a complex surgical table when a new technician and nurse question why this takes so long. The anesthesiologist and surgeon take a few minutes to explain the need to avoid pressure on the eyes, which might cause blindness, and how the ulnar nerves and brachial plexus can be damaged by pressure or incorrect arm positioning. Further, the external genitalia, bony prominences, and face are at risk. The surgeon asks whether that helped them to understand the importance of positioning for the patient, and the technician and nurse confirm their understanding.

Instructor Comments

  • Teaching Example.

Skills Needed

  • N.A.

Potential Tools

  • N.A.

Return to Contents


Scenario 82

 
Appropriate for: OR
Setting: Hospital

 

A 64-year-old obese male with an open ankle fracture and probable recent myocardial infarction presents to the Operating Room for a debridement and lavage. A radial artery is difficult to palpate, and an arterial catheterization cannot be performed despite attempts by the resident and the staff. A staff member shows the resident how to perform a brachial arterial catheterization using a single needle/wire/catheter technique and then replacing with a longer catheter via a modified Seldinger technique.

Instructor Comments

  • Teaching Example

Skills Needed

  • N.A.

Potential Tools

  • N.A.

Return to Contents


Scenario 83

 
Appropriate for: OR
Setting: Hospital

 

An experienced circulator is observing an inexperienced scrub struggle with passing free suture ties to the surgeon, with frustration growing for the surgeon and scrub. At a point during the surgery when the scrub is able to converse with the circulator, she explains that he should "pass the ties with the short end near the surgeon's thumb. This technique allows the surgeon not to have to reposition the suture before passing it around the clamp, resulting in a more expeditious flow during surgery." The novice passes the free tie as described, and the surgery progresses smoothly.

Instructor Comments

  • Teamwork and Coaching example

Skills Needed

  • N.A.

Potential Tools

  • N.A.

Return to Contents


Scenario 84

 
Appropriate for: OR
Setting: Hospital

 

During a long, difficult craniotomy, the chief neurosurgeon, Dr. Gluck, is unaware that he contaminated his right glove while adjusting the microscope. A new perioperative nurse, Andrew, notices the break in sterile technique. He states, "Dr. Gluck, let's change out your glove before you contaminate the instruments." Dr. Gluck responds, "You're wrong. Don't bother me while I am busy doing delicate surgery." Andrew reiterates the need to change gloves by pointing out a hole in the microscope drape to the surgeon. "Yes, you're right. I didn't see the hole in the drape," Dr. Gluck responds. He changes his glove, and the contaminated instruments are removed and replaced.

Instructor Comments

  • This scenario shows successful use of situation awareness and the Two-Challenge rule.

Skills Needed

  • Communication. Shared mental model. Situation awareness. Situation monitoring: assess environment. Mutual support.

Potential Tools

  • Conflict resolution, Two-Challenge rule, Advocacy/assertion, Collaboration.

Return to Contents
Return to Specialty Scenarios
Proceed to Next Section

Current as of March 2014
Internet Citation: TeamSTEPPS® Instructor Manual: Specialty Scenarios: OR. March 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/operroom.html