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SIGN ON Surgeons should mark sites as close as possible to the incision.The Joint Commission recruited the surgery center I ran in 2010 to join its pilot program aimed at improving safeguards to prevent wrong-site, -side and -patient surgical procedures. We went on to make 3 key enhancements to our policies and procedures. They might not strike you as major overhauls, but the fact is, the mundane, little things — the ones that can be easily overlooked — are probably your best areas of opportunity for improvement.
1. Pre-surgery validation. On the morning before the next surgical day, fax the case schedule to the surgeons' offices. By noon, their offices must check the schedule against their records, sign off on the patients and their scheduled procedures, and return their approvals by fax. If the fax-back contains a correction of any kind, immediately place a call to the scheduler who made the change to confirm. Document not only that a change was made, but also include the physician's orders that substantiated it in the patient's record.
PROVEN PRECAUTIONS
Reduce Wrong-Site Risks
ANY INVASIVE PROCEDURE Before injection or incision, mark sites and conduct time outs.Here are some practical ideas for ensuring you're performing the correct procedure at the correct site on the correct patient, based on advice offered by the Joint Commission in its Targeted Solutions Tool for overcoming common wrong-surgery oversights.
• Before the day of surgery: Confirm that the patients and procedures listed on the case schedule are accurate, and then ask physicians' schedulers to do the same. Establish and cultivate relationships with the schedulers to facilitate this process. Never accept verbal requests for surgery bookings. Instead, ask that schedulers send booking forms to a single fax number checked by a designated staff member. To improve scheduling accuracy, ask schedulers to use standardized language and abbreviations, and legible handwriting if they're not typed. To avoid forms slipping through the cracks, have a designated person in your facility manage the collection of required paperwork.
• In pre-op: Ensure required documentation is on hand and complete, including signed patient consents, histories and physicals, and physicians' orders. Have surgeons identify correct procedure locations by signing consistent marks (initials work well) as close as possible to the incision site. All site markings should be completed before patients are transferred to the OR. If a site cannot be marked, document the reasons in the surgical record.
• During time outs: After prepping solutions and drapes have been applied, match patients' identities and procedure locations — including site and side — using wristbands or patient involvement against the signed surgical consent. Assign specific and consistent roles to each member of the surgical team. For example, the surgeon and scrub tech should point to the marked surgical site and ask the surgical team to verbally confirm that it's correct. Don't rush the time out, and limit noise and activity so they don't distract the surgical team. Empower every team member to take part in the site verification and ensure they feel comfortable speaking up if they have concerns over any part of the process.
— Daniel Cook
ON THE WEB
Joint Commission Center for Transforming Healthcare
• Wrong-Site Surgery Targeted Solutions Tool
www.centerfortransforminghealthcare.org/tst_wss.aspx
2. Pause before regional. At the time of the pilot project, my center wasn't doing much ortho, so regional blocks weren't done regularly. But our process for placing blocks still needed correcting, as blocks are considered procedures in and of themselves from a wrong-site point of view. Have your medical director, anesthesia staff and director of nursing put together a policy stating that time outs need to happen with all regional blocks, and add a step to perioperative documentation to record the time-out's completion. It's not necessary to reinvent the wheel, just reinforce that the safety mindset before injection should be the same as before incision.
3. ID all sites. Note sites that can't be marked — many ENT procedures, such as tonsillectomy, for example — on patient wristbands. You might already have a wristband system in place to alert the care team to patients with allergies, so maintain the visual cue that everyone's familiar with. (Just make sure the site-alert bands are in a different color.) The idea is to heighten awareness to ensure all procedures and sites are identified — regardless of whether they can be marked.
Buy-in and barriers
The Joint Commission developed a Targeted Solutions Tool (TST) for wrong-site surgery that gives you access to downloadable resources and materials for doing quality improvement in your facility. Compare your current site-marking protocols to the Joint Commission's suggestions (see "Reduce Wrong-Site Risks" on page 14). Do you notice any room for improvement? If so, you might face some hurdles.
The biggest barrier might be all the tracking and paperwork required to know if change is actually happening at the front line. Before beginning our policy improvements, for example, we collected data for 30 days just so we could spot errors. After making changes, we tracked data for every procedure another 30 days, to validate the implementation of new practices. Although it's a lot of work, trust me: It'll all feel worthwhile when you reach full compliance.
One of the facilities I now manage recently used the TST to do its own quality improvement project. That facility has never had a wrong-site surgery, but the staff recognized the importance of assessing process-related risks and redesigning those processes to further reduce the chance of a wrong event's occurrence. They focused on nailing the time out every single time, and ended up implementing spot-checks to ensure ongoing compliance with demonstrated best practices.
Focusing on continuous quality improvement is the most important factor in preventing avoidable mishaps. Chances are, there's some aspect of your policies and procedures that can be improved upon. Never think, "Oh, we're not going to have a wrong-site surgery." Once you fall into complacency, you've set yourself up to make mistakes.
POLICY IMPROVEMENT
Make Change Happen
PUSHBACK Surgeons often resist wrong-site surgery precautions because they're reluctant to add steps to the care of every patient.So you know what needs improving in your site-marking policy, but the real issue is how to implement those improvements and make them stick. These 4 components to successful implementation are necessary, according to 70 facilities — a mix comprising roughly two-thirds hospitals, one-third ASCs — that shared with the Pennsylvania Patient Safety Authority their barriers to implementing wrong-site surgery prevention measures.
1. Leadership must establish the priority of implementation by empowering the nurses to enforce the facility's best practice policies and by providing the resources to improve systems and educate providers, including the physicians on the medical staff. Be aware that much of the pushback comes from physicians reluctant to add steps to the care of every surgical patient to prevent an event that may or may not happen to them personally in an entire career.
2. Manpower must be adequate to effect implementation — specifically surgical, anesthesia and nursing champions who will have the authority, time and resources to work with the frontline clinicians and business office staff so they can meet best practice goals in a way that acknowledges the realistic concerns of the hospital and medical staff.
3. Data on procedures must be captured, analyzed and discussed. Anecdotally, some of the pushback seems to be related to difficulty assembling all the information needed for verification, due to archaic information systems, including interfaces between surgeons' offices and hospitals.
Survey the frontline clinicians on the changes you want to make, and for their suggestions for improvements; they might present legitimate logistical reasons why change will be difficult. Use near-miss events to rationally drive quality improvement, policy and system changes, and education.
4. Patience must be practiced. Implementation takes time to co-opt early and late adopters — in our experience, about 6 months.
So what we're really talking about isn't motivation or encouragement, it's implementation science — what you need to do to create an environment that encourages compliance with behavior change, across an organization. This science involves the 4 components described above. One more thing: Although a degree of patience is key, so are follow-up and reinforcement. Because if you know there's a policeman patrolling a particular length of highway, you proceed with caution.
— John R. Clarke, MD
Dr. Clarke ([email protected]) is the editor of the Pennsylvania Patient Safety Advisory, clinical director of the Pennsylvania Patient Safety Authority and a professor of surgery at Drexel University.
ON THE WEB
Pennsylvania Patient Safety Authority
• 21 Recommendations and Barriers to Preventing Wrong-Site Surgery
bit.ly/UGH9DT
• Wrong-Site Surgery Toolkit
bit.ly/nTXLxH
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