# data[].attributes.body
Mark after shower
Check paper work
If no black mark check notes
Insuring staff are competent in what they have been asked to do
Prioritise patient over equipment - making sure equipment is sterislied before treating the patient
Communication between theatre staff - those carrying preop checks knew which limb but they did not communicate this with the surgery team

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Better training on protocols
Clear documentation of surgery site
Safe use of equipment
Ensure all appropriate resources are available
Safe staffing levels

# data[].attributes.body
-checking notes- being more vigilante
-more communication between mdt

-order of pre op steps- shower then marker pen
- new nurse needed proper training guidance in new setting and supervised
-communication between nurse and staff about skills and level of competency
-equiptment ready and available

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Marking the knee after the shower as normal procedure

Correct training and supervision for staff

Procedure in place to allow equipment to be ready in advance

Communication between patient and staff and furthermore different staff areas e.g. admin, ward and surgery (handover)

Pauses before and after surgery to brief and prepare staff for the procedure

Scheduled time between surgerys and organised staff, surgeon continuety

Communication with patients before procedure, helping them understand what's going to happen and what's expect of them

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Task factor site marked prior to shower.
Working factors- no stability within the team therefore staff aren't familiar with the environment
Organisation- schedule more time between procedures to allow for any faults/errors that occur.
Team factors- over confidence/lack of communication with other theatre team.
Individual- inexperienced scrub nurse, unfamiliar with procedure.
Team- handover from consultant/between the two nurses.
Education/training- needed better training on safety issues, ie. Not filling out the checklists accurately

Staff inductions when going to work in new areas

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- making sure all marking are clear after shower
-following all policies and procedures via operation
-breif for all staff before operation to ensure all staff are aware of the procedure
-making sure all equipment is working. Check this in advance of operation, if in doubt do not go ahead with operation.
-making sure all staff are aware of circumstances and aggre with the consent of the knee
-check consent form and paperwork rather than gathering information from people.
-making sure time management in place, to ensure patient safety is considered.
-

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1. Patient should wash before site is marked. Marking should be made before anaethesised so both patient and surgeon can check surgery site.
2. Site to be checked multiple times and also placed on surgery list. Surgery check list to be made visible and available at all times.
3. All new and unaware staff to be supervised until their confident and competent.
4. More equipment to be ordered and prepared in order for multiple surgeries to take place.
5. Team know each others level of knowledge and experience in order to confirm team skill mix to try avoid error.
6. Gain stability with theatre teams e.g same staff placed on rota to work together.

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Patient factors- wears wristband to symbolise allergies
Ensure all theatre staff have training on the Five Steps to Safer Surgery
Having a checklist to ensure all surgical procedures are organised
Keep equipment in working condition and wash spare parts immediately after use
Ensure all nurses are trained for their position and are aware of procedures and environment of the ward
Ensure all equipment is available and accessible.
Ensure all staff have undergone the correct training to be competent to carry out tasks designated to them.
Task factors site of op needed to be marked following a shower and should be continually checked prior to operating.

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More knowledge and skills required to actually practice in the theatre.
Adhere to the WHO check list.
Site should be confirmed before surgery begins.
Better hand over between staff and check if paper work matches the procedure taking place (double check everything)

Individual - if he was new to the operating department he should have been shadowed by somebody else or his work should have been double checked by somebody senior. More training should be put in place.

Mark after the shower and the patient should have let somebody know about it if they noticed it fading.

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Individual factors
1. Competence - senior nurse could go over the equipment before the operation with the newly qualified nurse or she could be supervised
2. Knowledge - nurse should be aware of surgical checklist
Working environment
1. Appropriate skill mix
2. Better preparation of equipment
Management
1. Making newly qualified nurse aware of policies related to workplace
2. Not having staff changeovers in the operation . Keep one surgeon on.
Organisational factors
1. Check notes before surgery to be aware of appropriate information.
2.

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Equipment availability issues (equipment and resources)
Inexperienced theatre nurse (individual staff factors)
Site not marked prior to surgery - mark removed and unreported (task factor/patient factor (for not noticing))
Information not communicated in briefing (communication factors)
Reduced team vigilance where routine straightforward case is carried out (team factors)
He marked the knee BEFORE telling her to wash up and have a shower (organisational failings

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1. Have the wash done before surgery done properly.
2. Patient made aware of the importance of the mark on her leg so she knew once it faded to tell someone before the surgery
3. Mark should of been put on the patient after she had the shower
4. Sterilise spare equipment as soon as soon as possible in case of faulty main equipment.
5. Properly train the scrub nurse and make sure she is competent in all aspects of the theatre procedures.
6. If unsure, ask!

# data[].attributes.body
Better communication
Training. Increasing knowledge of procedures
Organisation
Should've remarked the knee or marked the knee post shower
Safe staffing levels
Should've done extra checks rather than going off the x-ray and should read the notes as well
Handover before and after operations
New nurse should be supervised until confident
Senior nursing supervision by of inexperienced threat nurse

# data[].attributes.body
Better communication between staff and patients
Staff who are new need to be trained so that each procedure is performed correctly and confidently
Supervision not the nurse and surgeon
Double checking charts and allergies as well as checklists
Showering before markings innthe knees Reading patient case notes and understanding the procedure
Making sure information isn't!over correctly from one professionals to another
Making sure equipment is prepared and ready before surgery
By Courtney