Transcript Battling Wrong Site Surgery - Association of periOperative
Battling Wrong Site Surgery
Rhonda L. Anders, MSM, BSN, RN, CNOR, NE-BC Director, Perioperative Services Franciscan St. Francis Health Indianapolis, IN November 18, 2013
Rhonda Anders, MSM,BSN,RN,CNOR,NEBC
R HONDA A NDERS HAS BEEN A PERIOPERATIVE REGISTERED NURSE FOR HAS FULFILLED THE FOLLOWING ROLES : S TAFF N URSE , C LINICAL 23 YEARS AND E DUCATOR , C LINICAL M ANAGER , AND P ERIOPERATIVE S ERVICES D IRECTOR . A S SHE PROGRESSED THROUGH THE VARIOUS STAGES OF HER CAREER , SHE RELIED MORE HEAVILY ON EVIDENCE BASED PRACTICE AND ENGAGEMENT WITH OF D IRECTORS FROM M ARCH AORN. S HE SERVED 2007 – M ARCH 2011. S AORN ON THE N ATIONAL B OARD HE HAS PREPARED AND PRESENTED DOZENS OF EVIDENCE BASED PRESENTATIONS RELATED TO SAFETY IN THE PERIOPERATIVE SETTING .
Disclosure Information
Speaker:
Rhonda Anders, MSM,BSN,RN,CNOR,NEBC
Discloses no conflict
Planning Committee:
Ellice Mellinger MS, BSN, RN, CNOR
Discloses no conflict
AORN’s policy is that the subject matter experts for this product must disclose any financial relationship in a company providing grant funds and/or a company whose product(s) may be discussed or used during the educational activity. Financial disclosure will include the name of the company and/or product and the type of financial relationship, and includes relationships that are in place at the time of the activity or were in place in the 12 months preceding the activity. Disclosures for this activity are indicated according to the following numeric categories: 1.
Consultant/Speaker’s Bureau: 2.
Employee 3.
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Stockholder Product Designer Grant/Research Support : Other relationship (specify) : 7. Has no financial interest: None
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AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019.
AORN IS PLEASED TO PROVIDE THIS WEBINAR ON THIS IMPORTANT TOPIC. HOWEVER, THE VIEWS EXPRESSED IN THIS WEBINAR ARE THOSE OF THE PRESENTERS AND DO NOT NECESSARILY REPRESENT THE VIEWS OF, AND SHOULD NOT BE ATTRIBUTED TO AORN.
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Learning Objectives • Catalogue early attempts at preventing wrong site surgery • Analyze the impact of culture on wrong site surgery • Compose tactics for the prevention of wrong site surgery
Battling Wrong Site Surgery
Introducing Time Outs: Our Primary Weapon
January 2003 National Patient Safety Goals
1. To improve the accuracy of patient identification by using two patient identifiers and a time out procedure before invasive procedures 2. To eliminate wrong-site, wrong-patient, and wrong procedure surgery using a preoperative verification process to confirm documents, and to implement a process to mark the surgical site and involve the patient/family Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries.
AORN Connections
, 5-6
The Joint Commission 2004 Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery
Key Defenses in the Battle:
The Time Out
Preoperative Verification Process
Marking of the Operative Site
Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries. AORN Connections, 5-6
AORN’s 2004 Contributions to the Battle
Correct Site Surgery Tool Kit National Time Out Day
Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries.
AORN Connections
, 5-6.
TJC’s Center for Transforming Healthcare Adds to Our Arsenal
2009 Wrong Site Surgery Project
Booking Errors
Verification Errors
Errors Caused by Distracting or Rushing
Elements of the time out not verbalized
Inconsistent Site Marking
Lack of a Fully Functioning Safety Culture
Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries. AORN Connections, 5-6
Targeted Solutions Tool for Wrong Site Surgery
February 2012 Developed from Findings of the Wrong Site Surgery Project:
Guides healthcare providers through a step-by step process to assess their vulnerabilities
Risk begins as the case is booked due to variations in processes
Identifies specific risk factors unique to each organization
http://www.centerfortransforminghealthcare.org/
DeJohn, P. (2012). Joint Commission tools to prevent wrong surgery. OR Manager, 1-3.
All These Weapons Have Reduced Wrong Site Surgery in the United States
False
US Department of Energy (DOE) Guiding Principles of Safety
Leadership Commitment is Essential for Creating a Culture of Safety
•
Senior managers demonstrate their commitment to safety in both word and action
• •
Patient safety leadership walk rounds Safety Attitudes Questionnaire
Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.
Safety Attitudes Questionnaire
Courtesy of Pascal Metrics, Inc. 2013.
US Department of Energy Guiding Principles of Safety
• •
Everyone is Responsible for Safety
Regardless of position or level within the organization, everyone must be empowered to raise safety issues or question an action that compromises safety The ability of staff to raise concerns influences safety
Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.
Safety Attitudes Questionnaire
Courtesy of Pascal Metrics, Inc. 2013.
US Department of Energy Guiding Principles of Safety
Empower Governing Bodies to Create and Enforce Safety Policies Defense Nuclear Facilities Safety Board (1988)
Congress charged this independent oversight organization to develop
meaningful safety standards ensure consistent requirements for management and contractors
raise technical competence to ensure protection of workers and the public
Created industry wide process to review, identify, and prevent hazards and share best practices to improve safety Agency for Healthcare Research and Quality (AHRQ)
Called for a single national healthcare safety body to coordinate standards and deliver widespread communication regarding safer health care policies
Tubing and catheter connection errors: brought forth the need to standardize safety approaches with connections
Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.
US Department of Energy Safety Standards
• • • •
Eliminate Preventable Harm Identified In Progress Injuries are preventable DOE sets the safety goal to ZERO Injuries, events, and accidents are not tolerated Learning mentality for prevention and improvement involves critique, investigation and correction.
Defect, or near miss identified by front line staff, dated, and placed on this section of the Learning Board Identified issues placed here when “who” is assigned to address
Resolved
When the issue is resolved, or problem solved, it is placed here along with a date of completion Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.
Learning Board in Action
Identified In Progress Resolved
Patient stated, “Total Hysterectomy” while consent stated, “Vaginal Hysterectomy”. No mention of Salping oopherectomy. What is Manager to determine how to incorporate patients’ verbiage into consent forms to the meaning of Total assure that what they Hysterectomy to a patient? Is this a wrong procedure about to occur?
Assigned to Quality Manager and OR believe is about to occur is congruent with what the OR team believes is about to occur.
Consent re-designed to prompt additional dialogue free of medical jargon. New consent stresses the importance of understanding what the procedure is in the patients’ own words.
New Language in Consents
• •
Authorization For and Consent to Surgical Operations, Diagnostic and Therapeutic Procedures
• Doctor/or designee should write proposed procedure here
in the patient’s own words
Please tell me, in your own words, the proposed procedure you are having: ____________________________________________ ____________________________________________
Learning Board Fighting Wrong Site Surgery at All Levels
Identified
Case was scheduled as “left carpel tunnel decompression”. It should have been scheduled as “left carpel tunnel decompression, left cubital tunnel release”.
In Progress
Assigned to Surgery Scheduling Supervisor. Explore documentation of request from Dr. X’s office, examine processes to determine where defect occurred.
Resolved
Establish a Universal, Uniform Approach for Safety Management
•
Integrate safety into all facets of work planning and practices.
•
Hazards must be understood with preventative controls in place before engaging in any activity
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Clear and unambiguous roles and responsibilities are established for ensuing safety.
•
Use of Checklists
Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.
US Department of Energy Guiding Principles of Safety
Mandate Reporting of Safety Issues, Errors and Near Misses
•
DOE views front line staff as most important resource for preventing and reporting hazards and potentially unsafe practices
•
An effective reporting culture encourages and maintains employees’ open expression of concerns with no fear of retaliation
Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.
Mandate Reporting of Safety Issues, Errors and Near Misses Continued
• •
Near misses signal system weaknesses, and because harm did not occur, may provide insight into solutions Although the national Patient Safety Quality and Improvement Act of 2005 provides confidentiality for reports of medical errors to accredited patient safety organizations, only 27 states require hospitals and/or other medical facilities to report serious medical errors
Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.
Identifying Weakness
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Repeated reports of missing instruments and instrument set sheet not matching actual contents
• •
Repeated reports of missing indicators in sets Reports of incorrect packaging for peel packs TROUBLE IN CENTRAL STERILE PROCESSING (CSP)!
Taking Action Before Harm
• • -
Reviewed hours worked by CSP staff No one with less than 90 hours pay for last 3 pay periods. One employee at 153 hours / pay Implemented instrument tracking system required the updating of all set sheets gives us the ability to identify where defects occur in the process
• -
Added annual mandatory training to review sterilization indicators and peel packs that go with the different methods of sterilization
US Department of Energy Guiding Principles of Safety
Cultivate Learning as Part of the Organizational Mentality
Open trusting environment Focus on injury prevention Front line staff freely question processes Sense of ownership for improving the workplace
Mechanisms such as occurrence reporting, incident investigation, root cause analysis, and self assessments contribute to the learning process.
Medical simulation enhancing learning cultures across healthcare continuum
Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.
Four Components to the Briefing
Everyone knows the game plan
Psychological safety is ensured
Norms of conduct are discussed
Expectation of excellence is set
Berenholtz, S., Schumacher, K., Hayanga, A., Simon, M., Goeschel, C., Pronovost, P., et al. (2009). Implementing standardized operating room briefings and debriefings at a large regional medical center.
Joint Commission Journal on Quality and Patient Safety
, 391-397.
The Briefing Creating Connection with the Patient
Is it…Our patient Rhonda Anders, Is it the gallbladder in room 9….or…
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46-year old female Recent history of tibial plateau fracture followed by a series of Deep Vein Thrombosis (DVT) Currently taking 6 mg of Coumadin daily with an INR of 2.6
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She’s showing signs of sepsis so we’ve got to get her gallbladder out today
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I have no special equipment or instrument needs
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But does this information raise questions for any of you?
The Briefing Creating Connection as a Team
Surgeon: “Hey guys.” Surgeon: “Hey guys.” Staff: “Good morning Dr. Mandelbaum.” Anesthesiologist, “Hey Jon, how was your trip to Florida last week?” RN Circulator: “Good morning Dr. Mandelbaum. This is Stacy Wilson. She’s a new nurse with us at St. Francis, but not new to the OR” Stacy RN: “I’ve been in the OR for the past 12 years. Nice to meet you” New employee scrubbed in but never introduced… Or… Anesthesiologist: “You used to work at Methodist, didn’t you? I thought I recognized you” Dr. Mandelbaum: “If any of our equipment or supplies look foreign to you, be sure to ask your preceptor or me for information”
Debriefing is the element that links
teamwork and improvement
Berenholtz, S., Schumacher, K., Hayanga, A., Simon, M., Goeschel, C., Pronovost, P., et al. (2009). Implementing standardized operating room briefings and debriefings at a large regional medical center. Joint Commission Journal on Quality and Patient Safety, 391-397.
The Debriefing Creating a Learning Organization
Surgeon: “Thanks everybody. Go ahead and get the next patient into the room as soon as you can. I’m going over to 3 West for a few minutes to round.” RN Circulator : “Let’s do the debriefing now. What went well today?” Staff: “Okay, we’ll page you when the patient is in the room.” Surgeon : “Everything from my perspective, you guys did a great job, thanks. Stacy, nice job! Was there anything you would have liked to have been different?” Anesthesiologist: “See you in about 20 minutes, okay…?” Or… Scrub : “The lap chole set had a hole in the wrapper. Can you write up a defect sheet and request that this set go into a rigid container.” RN Circulator : “ Will do. Is there anything we should do differently next time?” New Staff Member Stacy RN : “Yes, I didn’t know Dr. Mandelbaum’s special instruments. I felt like I was fumbling. Can you go over those with me before the next case.”
Communicate Clearly The Least Expensive Weapon!
Structured Communication
SBAR
S ituation
B ackground
A ssessment
R ecommendation
Repeat Back
Structured Critical Language
Critical Language A Phrase That Stops the Work
• • • •
“I need a little clarity” “I am concerned” “I am unclear” “This is unsafe”
Stopping the Work
Surgery Attendant (SA) arrives at entrance doors to room 12 with patient. The RN Circulator sees the patient and says, “ Stop! I have a concern I need to address.”
• • •
To SA and Patient, the RN Circulator says: “I’ll be right out to explain.” Rooms 12 and 14 were doing Total Joint Jump Rooms Room 14’s patient was about to be brought into Room 12 They were both having total hip replacements, but on different sides. What if…
Environment Rife with Embarrassment or Psychological Safety Embarrass: Feel self-conscious or ill at ease Have your composure Psychological Safety: A belief that one will not be humiliated or punished for disturbed Feel uncomfortable because of shame or wounded pride speaking up with ideas, questions, concerns, or mistakes A shared sense of psychological safety is a critical element in an effective learning system Edmondson, A. (1996). Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, 350-383.
Do You Have to Protect Your Image at Work?
To Protect One’s Image: If you don’t want to look… STUPID •
Don’t ask questions
INCOMPETENT NEGATIVE DISRUPTIVE • • •
Don’t ask for feedback on your performance Don’t look doubtful or criticize Don’t suggest anything innovative
•
Edmondson, A. (1996). Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, 350-383.
Psychological Safety to Question the Status Quo
Stupid Incompetent Negative Disruptive
• • • •
Ask Questions Ask for Feedback Be Doubtful Be Innovative
Edmondson, A. (1996). Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, 350-383.
The Fight Continues… Use ALL Weapons at Your Disposal Time Out Preop Verification Site Marking Checklists CSS Tool Kit National Time Out Day Targeted Solutions Tool Briefing Skilled Communication Debriefing Learning Culture Psychological Safety
References Berenholtz, S., Schumacher, K., Hayanga, A., Simon, M., Goeschel, C., Pronovost, P., et al. (2009). Implementing standardized operating room briefings and debriefings at a large regional medical center. Joint Commission Journal on Quality and Patient Safety, 391-397. Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240. DeJohn, P. (2012). Joint Commission tools to prevent wrong surgery. OR Manager, 1-3. Edmondson, A. (1996). Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, 350-383. Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries. AORN Connections, 5-6.