Doing the Right Things to Correct Wrong-Site Surgery

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Doing the Right Things to PREVENT Wrong-Site
Surgery
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• More than 40 times/week in the United States, a
  surgeon cuts into a patient or an
  anesthesiologist places a nerve block, only to
  realize that the scalpel or needle belonged
  somewhere else.
• Anesthesiology News March 2011

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Incidence of Never events

• Fire (100/year or 1/530,000 cases)
• Wrong site (2500/year or 1/21,200)
• Retained object (1000/year or 1/53,000)

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Incidence of Manufacturing Defects

• Six Sigma goals defects lt1/1000
• Best automaker 1/20,000

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Kwaan, et al, Arch Surg.2006141353-358

• Wrong site surgery is unacceptable but
  exceedingly rare, and major injury from
  wrong-site surgery is even rarer

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Doctor who removed the wrong lung, killed patient
working again at Hoboken University Medical
Center By The Jersey Journal January 31, 2010,
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Wrong-site Surgery by Specialty

• Orthopedic
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• General surgery
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• Anesthesiology 20
• Neurosurgery
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• Urologic surgery
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• CVS, ENT, dental, eye
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Wrong-Site Incidence (PSA 04-06)
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Location of Wrong-Site Surgery
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• To be frank, wrong-site surgeries should never
  occur Dr. Paul Schyve, senior vice president at
  The Joint Commision 2007 Wrong-Site Summit

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HUMAN ERROR!
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Error is Inevitable Because of Human Limitations

• Limited memory capacity 5-7 pieces of
  information in short term memory
• Negative effects of stress error rates
• Tunnel vision
• Negative influence of fatigue and other
  physiological factors
• Limited ability to multitask

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People error

• Fact of Life
• We are not machines
• Creativity, adaptability, flexibility are our
  strengths
• Continual alertness, precision in action or
  memory are our weakness

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Wrong-Site by Distribution

• Emergency cases
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• Unusual time pressure
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• Unusual equipment or set-up in the OR 13
• Multiple surgeons
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• Multiple procedures with same patient 10

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• WRONG SITE SURGERY-
• HUMAN OR SYSTEM

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Both Human And System Errors

• Forgetfulness
• Carelessness
• Poor communication
• Team member changes
• Fatigue

• Poorly designed risk management techniques
• Imperfect technology
• Inadequate cross-organizational communications

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• Should we just accept wrong site surgery as
  inevitable and hope we are not exposed to it
  during our careers?

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Universal Protocal(Last revised 2009)

• Three (3) Phases
• 1. Preoperative verification process
• 2. Marking the operative site
• (person performing procedure)
• 3. Time out

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• Still, the number of events reported to the
  Joint Commission has not changed significantly.
  And thenumbers of reported cases in
  Pennsylvania, New York, Florida, or Minnesota
  have not changed. Ann Surg 2009

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However beautiful the strategy, you should
occasionally look at the results. Sir Winston
ChurchillBritish politician (1874 - 1965)
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Florida (2001)

• Stiff fines
• Risk management training
• Community service
• 1 hour lecture to medical community

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• I have climbed Mount Rainier five times. Each
• time I made that tough trek, my risk of dying
• was about 100 times smaller than the risk I will
• face on the operating table. Don Berwick,
• director of the Centers for Medicare and Medicaid
  
• Services (CMS)

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Checklist

• Checklist nothing new
• Shopping
• Flying planes
• Homework assignment notebooks

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Th e new england journal o f medicine n engl j
med 3605 nejm.org january 29, 2009 491 special
article A Surgical Safety Checklist to Reduce
Morbidity and Mortality in a Global Population
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Checklist study

• 8 hospitals thruout the world
• 6 safety measures
• Airway assessment
• Pulseox
• Adequate iv access for blood
• Appropriate antibiotics
• Identify pt , procedure and site
• Sponge count

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Checklist study

• Death rate decreased 100 (1.5 to .8)
• SSI and unplanned reoperation also decreased by
  100 (6.2 to 3.4)
• All complications decreased from 11-7
• Implementation neither costly nor lenghty

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Checklist for CVL insertion

• Wash hands
• Clean skin with chlorohexidine
• Cover patient and procedurist
• Avoid groin catheters
• Take out when not needed

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How can Something so Simple Accomplish so Much?
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A checklist is a type of informational job aid
used to reduce failure by compensating for
potential limits of human memory and attention.
It helps to ensure consistency and completeness
in carrying out a task. A basic example is the
"to do list." A more advanced checklist would be
a schedule, which lays out tasks to be done
according to time of day or other factors.
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Aviation industry has relied on checklists to
improve safety since the 1930s
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Checklist Concerns

• Mindless machines
• Protocol rigidity
• Heads down in a checklist unable to look to look
  out the windshield and cope with the real world
  ahead of them

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Checklist Roadblocks

• Teamwork perceptions, 64 surgeons, 39
  anesthetists, 28 nurses, 10 surgical
  technicians rated high level of teamwork
• Trained to be specialists Thats not my area
• Culture The OR is the surgeons stage
• Silent disengagement
• 25-40 of RNs say they would be hesitant to speak
  up if they saw a physician making a mistake.

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Checklist Reality

• Checklist use for every case will improve
  communication, engagement and teamwork
• Hospitals that have started to use them report
  increase staff job satisfaction
• Also has caught numerous near misses
• 250 OR staff survey, 75 witnessed error rescue,
  80 found useful, 93 would request checklist
  before own surgery

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Checklist reality

• Well made checklist
• Gets the dumb stuff out of the way (MAIDS)
• Lets one focus on the hard stuff (42 steps in
  TKR)
• Crisis management lessons
• First moments spent in denial and wondering what
  went wrong
• FLY THE AIRPLANE

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OR TEAM INTRODUCTIONS
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How does the checklist help?Activation
Phenomenon

• How we set the tone in the first 10 seconds in
  the OR has a profound impact on whether people
  will comfortably voice concerns.
• Staff formally introduce themselves
• Briefly discuss critical aspects of a given case
• Seems to activate a sense of participation,
  responsibility, and willingness to speak up

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Collaborate rather than Compete

• Definition of
• collaboration
• To labor together.
• To work jointly with others or together.
• 3. To learn from one another.
• 4. To trust, support, value one another.

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OUR CHECKLIST JOURNEY
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Must have data available to argue for change

• NEJM study
• Money talks
• Decrease staff turnover
• Decreased patient complaints
• Word of mouth when satisfied (One negative
  comment can be passed on to 67 people)
• Decreased litigation

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Embrace a new mindset

• Acknowledging our vulnerability to make mistakes.
• Unlearn what we learned in school. Reliance on
  professional/individual responsibility.
• Human factors such as environment, stress, noise,
  etc. influence our work.
• Flatten the hierarchy.
• Communicate, communicate, communicate

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Changes to Processes to make Patient Care Safer

• Simplify
• Standardize
• Checklists (Reduce reliance on memory)
• Eliminate look alikes and sound alikes
• Training
• Increase communication and feedback
• Teamwork
• Adjust environment
• Adjust work schedules

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• Set the Standard
• Follow the Standard
• Look for a Better Way

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Real Case Examples