Wrong Site Surgery: What we know, what we are learning - PowerPoint PPT Presentation

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Wrong Site Surgery: What we know, what we are learning

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Tech identified problem, reluctant to speak up ... 8 reported to not have active verbal time out by entire surgical team prior to incision ... – PowerPoint PPT presentation

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Title: Wrong Site Surgery: What we know, what we are learning


1
Wrong Site Surgery What we know, what we are
learning
  • Diane Rydrych
  • Division of Health Policy
  • MN Department of Health

2
Overview
  • How common is WSS in MN, and what does it look
    like?
  • What does national data show?
  • Why does WSS happen?
  • How well do MN facilities follow the safe-site
    surgery protocol?

3
WSS in Minnesota
4
WSS in Minnesota
5
Where does WSS happen?
6
Types of Procedures
7
Patient Outcomes
8
VA National Center for Patient Safety
  • 1/30,000 surgeries, 1 WSS/month (2001)
  • 44 left/right mix-ups
  • 36 wrong patient
  • 14 wrong implant or procedure
  • 7 wrong site (not left/right)

9
VA National Center for Patient Safety
  • Eye
  • Groin or Genitals
  • Chest
  • Leg
  • Hand, Wrist, or Finger
  • Abdomen
  • Back
  • Head, Neck, Mouth, Anus, Colon, Buttock

10
Joint Commission
11
Pennsylvanias experience
  • 174 WSS cases and 239 near misses in 30 months

Source Annals of Surgery, September 2007
12
Pennsylvanias experience
  • Which factors contributed most strongly to
    prevention?
  • Surgeon being involved in pre-op verification and
    reconciliation, including verification with
    office records, consent, and medical records
  • Having correct and complete information for
    pre-op verification
  • Participation by anesthesia in time-out before
    patient is touched
  • Correct site marking and patient positioning/prep

13
Pennsylvanias experience
  • Recommendations
  • Full surgeon involvement in verification and
    time-out, possibly through pre-op briefing
  • Include site/side on consent form and in notes
  • Include all relevant documentation in
    verification
  • Mini-time out with any repositioning
  • Have reliable system for transmitting info from
    surgeons office to OR nurse/team
  • Team training for OR
  • Surgeon discusses any changes in plan or new
    information with team

14
Preventing WSS
  • But..we have a protocol to prevent WSS, right?
  • We do. But do we use it?

15
Preventing WSS
  • Registry modified to include questions related to
    protocol
  • Did OR schedule and consent match?
  • Did the surgeon sign the site in pre-op?
  • Did he/she sign with initials?
  • Was there active, verbal participation in a
    time-out?
  • Was there a second pause for internal laterality?
  • For spinal procedures, pre-op and intra-op x-rays?

16
Preventing WSS
  • OR schedule/consent matched 13.8 No
  • Surgeon signed site 54.3 No
  • Surgeon signed site with initials 51.4 No
  • Surgeon signed site with initials 45.7 No
  • Every step followed zero

17
Preventing WSS
  • What went wrong?
  • Incomplete/unclear policies
  • No policy in some parts of facility
  • Chaos/confusion/distraction
  • Cultural issues
  • Visibility of site marking
  • Lack of team involvement
  • Time pressures/staffing
  • Communication breakdown
  • Training
  • Existing policy not followed

18
Preventing WSS
  • Incomplete/unclear policies
  • No standardized process for marking spine levels
  • No second time out for internal laterality
  • Inconsistent understanding of pause leading to
    varying practices
  • No single person assigned to call pause
  • Policy doesnt include certain elements of
    protocol (comparing chart with consent, verifying
    lens/implant, etc)

19
Preventing WSS
  • Chaos/confusion/distractions
  • Different types of procedures done in single
    space, leading to chaotic environment
  • Circulator distracted, couldnt gather
    documentation
  • Staff preoccupied, didnt engage in pause
  • No cue to focus team for final pause
  • Non-OR environment can have too much noise to
    allow focus on procedure/protocol

20
Preventing WSS
  • Cultural Issues
  • Physicians in OR have own standard of practice
    staff reluctant to speak up
  • Tech identified problem, reluctant to speak up
  • Everyone trusted each other and assumed things
    were correct no pause
  • Staff didnt know how to get MD attention about
    possible WSS without alerting patient
  • MD disregarded request to mark site per policy

21
Preventing WSS
  • Visibility of site marking
  • Mark obscured by betadine prep
  • Site marked with ballpoint pen, not visible
    during pause
  • Patient repositioned, site not visible
  • Site mark had faded, directions to remark site
    unclear

22
Preventing WSS
  • Other
  • Not all staff participated in time out
  • Laterality of procedure incorrectly communicated
    to team
  • Procedure completed before pause
  • Anesthesiologist working alone did not do pause
    before regional block
  • High demand for procedure room leads to time
    pressures
  • Not all staff trained on protocol
  • Facility did not reinforce that protocol needs to
    happen EVERY TIME

23
First edition of protocol


  • Site marking
  • Verification process/
  • informed consent
  • Time-out process
  • Protocol available
  • at www.icsi.org








24
A turning point


  • CEO and operations group decided to do an
    event analysis.
  • All 14 cases from Jan. 2003 to June 2004 were
    reviewed.
  • Information was sum-marized and themes and common
    learnings were shared.


                              






25
Case/event analysis


  • 14 events
  • 10 of 14 Wrong site
  • 4 of 14 Wrong procedure
  • 5 of 14 Spinal procedures (others were
    misc.)
  • Event analyses were put into 3 categories
  • One or more parts of protocol werent followed.
  • Protocol needed to be strengthened in a
    particular area.
  • Event was caused by a system failure outside the
    OR.


                              






26
Two immediate responses to findings


  • For spinal surgeries, protocol was revised to
    require four specific steps site marking with
    surgeon initials, pre op x-ray of good quality,
    intra-op x-ray with opaque instructions marking
    the specific bony landmarks, comparison of pre-op
    and intra-op x-ray
  • 2. CEOs instituted hard stop policy to begin
    Feb. 2005 No protocol, no surgery


                              






27
Summary of protocol enhancements through 2006
  • Standardized spine protocol
  • Several clarifications surround site marking
  • Specific verification process for implants

28
Summary of protocol enhancements through 2006
  • Specific verification process for internal
    laterality
  • Time out process requirement for regional
    blocks
  • Alerts such as anatomical variation

29
2003 2006 events
  • This information is on the 30 events
  • 5 reported to have followed all of the parts of
    the protocol
  • 4 reported to not have a signed informed consent
    or did not verify inconsistent information on
    informed consent, schedule, and/or patient chart
  • 7 reported to not have site marked
    appropriately/at all by surgeon in pre-op
  • 8 reported to not have active verbal time out by
    entire surgical team prior to incision
  • 3 reported to not have followed the spine
    specific part of the protocol

30
Event summary 1st half 2007
  • 7 additional events (more in 3rd Q yet to be
    discussed) - data below are on 6 of the 7 events
  • 5 wrong site/side
  • 1 wrong piece of equipment
  • Protocol components not followed (more than one
    applied to some events)
  • 1 did not have site marked
  • 2 did not verify consent, schedule, patient chart
  • 5 did not do an active, verbal, time out

31
Ongoing learningsin 07
  • Anesthesia blocks on wrong side - not following
    the newest addition to the protocol around
    anesthesia pause and verification by 2 people
    prior to anesthesia being administered.
  • Verbal, active pause for the cause/time out
    continues to be a significant problem in 2007,
    and then subsequently performing the intra-op
    pause/time out prior to products/implants to be
    used during the surgery.
  • Suggestion to add to the protocol a second pause
    if the patient has been repositioned in any way.

32
Sharing and learning from surgical events
  • Need transparency if we want to improve
  • Through the RCSC collaborative
  • Through MDH never event reporting
  • Sharing the details of the events is paramount to
    improvement
  • Broad knowledge of the vast experiences and
    situations
  • Power of open sharing across the hospitals
  • Continually improves the protocols and
    implementation tools and techniques that pushes
    us towards standardization and reliability

33
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