Transcript Making the Site Right - McMaster Faculty of Health Sciences

PATIENT SAFETY
The process of ensuring Correct
patient/side/site procedure
Deepak Dath, BSc. MD MEd FRCSC FACS
CORE, April 8th 2009
OBJECTIVES
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History
The concept of safe site surgery
Current status
How to make it better
Policy
What is new and coming
History
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Boy skins shin while skateboarding
Man trips, looses balance, spills
milk from glass – wife upset
Woman at university writes
examination
History
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Man gets $0.85m after wrong
surgery
Surgeon faces discipline for
removing wrong breast
© St. Petersburg Times
Patient Outcome is an
OLD CONCEPT
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Ernest Codman, 1910
A surgeon at the turn of the last century
Look at the name on the instruments in your OR
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Worked at Harvard and started the first M&M
rounds!!!!
Got kicked out of HARVARD when he
proposed to check surgical outcomes
So, he started his own hospital and, …
Over 5 years, he treats 337 patients and
publishes 123 errors!!!
Ernest Codman
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Proposes the end result system of
hospital standardization
Gets the American College of Surgeons
(with the CMA) to start accrediting
hospitals!!!
Teaching points:
Advocate
Professional
Manager
Medical Expert
Collaborator
Scholar
History
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NEJM article, based on the book:
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100 000 medical errors/year in USA
Small percentage of these are wrong
patient/wrong site/wrong side/wrong
procedure
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Devastating, sometimes irreparable
Joint Commission on the Accreditation of
Hospitals (JCAHO) took on the job of
identifying why and changing outcomes
History
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Root cause analysis used to pry into
the 15 cases that came to light
Asks not “Why?” but
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“How is it that ……”
(old Japanese technique)
Made recommendations
July 1 2004 – no hospital receives
accreditation without compliance
History
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Orthopaedic associations
Nursing Associations
Surgical Associations
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All have been suggesting similar techniques for
many years (varyingly robust)
This is the first wholesale effort to wipe
out this problem
No similar effort in Canada
safe site surgery
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Performance of:
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The correct procedure;
On the correct patient;
On the correct side;
At the correct site
safe site surgery
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Wrong site surgery:
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rare but devastating occurrence
It occurs when there is no:
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Easy
Systematic
Redundant
Failsafe
procedure for ensuring that the correct site
is being treated
safe site surgery
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Patient identification:
Methods needed to ensure the right
patient is being treated
Patient identity is confirmed and
communicated at each transfer
Good oral communication between
health care workers
safe site surgery
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Procedure and site verification:
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Discussion with patient
Consult notes (H&P)
Consent
Imaging studies
Other relevant documentation
Correct implant if applicable
safe site surgery
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Site Marking:
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Universal process
Involves a member of the surgical team
who will be operating
Occurs generally prior to transfer to
Operating room
Exceptions
safe site surgery
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The “Surgical Pause” or “Time Out”
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ALL members in the room verbally agree to
the procedure being done
Anyone can challenge prior to the
procedure starting
Method in place to review case if there is
not consensus
The Current Status in my office
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I get consent from the patient
personally
Sign consent with the patient, reading
operation to them
Fill out the booking request at the same
time
Communicate the operation with my
secretary
The Current Status at SJHH
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Centralized booking clerk and distribution
centre (Sandra)
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Prevents duplication errors
Patient arrives in DSU and is checked in with
verification of identity/procedure and site as
well as presence of documentation
Patient is checked when taken to Holding
The Current Status at SJHH
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Patient is checked by OR nurse outside
the room or before being placed on the
operating table
Anaesthesia commences
Surgical Pause
Surgery commences
What are we missing?
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Correlation of information?
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Marking of site (not standard)
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Surgical Pause (not done robustly)
Correlation
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Need to correlate all sources of info:
Consent and consult and booking form
Imaging
Patient’s expectation
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Communicate this down the line
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Marking
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Should be done prior to the operating
room
Marked on skin (not removable with
prep, no stick-on marking)
Surgeon or resident should sign the site
No extraneous marks
Patient involved (tell them it will happen
when you first see them)
Marking
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Exceptions:
Laparoscopic surgery
Midline Surgery
Single orifice surgery
Where decision is made intraop
Spinal Level (intraop marking)
Marking
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DSU?
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Holding?
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Outside OR?
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Emergency cases?
Surgical Pause
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Probably the single most important step
Reluctance in places where it does not
exist.
Takes a few seconds
Empowers all members to be
responsible
The real “failsafe”
Policy
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Presented to the surgical staff
Unanimous approval to move forward
policy drafted and implemented
Added to a revamped checklist
Circulating Nurse in charge of
documenting the event
Need “Buy-in” from everyone for this to
be successful
What is new and coming
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Atul Gawande
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“Complications”
Surgical barcoding
Safe Surgery Saves Lives
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WHO
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Canadian Patient Safety Institute
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Propmpts the use of a Canadian version of
the WHO checklist