Positioned to Prevent Wrong-site Surgery

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Reinforcing a culture of safety will ensure surgeries are performed as planned.


Adverse events involving wrong-site, wrong-side and wrong-patient errors are devastating outcomes for surgeons who must live with the mistakes and patients who suffer unnecessary physical scars. These never events persist because of inconsistencies in implementing proven steps to prevent them. Ensuring surgeons perform the correct procedure on the right patient at the intended site requires a multidisciplinary effort and refocusing on the importance of building a culture of safety.

University of Pittsburgh Medical Center (UPMC) facilities are known for adherence to strict patient safety measures, including a series of steps designed to prevent wrong-site surgery. The effort begins long before patients are wheeled into the OR.

  • Confirm with schedulers. Surgeons' offices send in surgery reservation sheets, which note patients' names and details about the procedures they're scheduled to undergo. A day before scheduled cases, UPMC staff members call surgeons' offices to review the list of patients and confirm the correct procedures, and then add the information to the surgical schedule in the health system's electronic medical record.
  • Perform multiple checks. The reservation sheet is forwarded to the pre-op testing department, where staff verify the correct procedure when they call patients to collect standard health histories. In pre-op on the day of surgery, staff members ask patients to confirm their names, dates of birth, procedures and surgical sites, and make sure each identifier matches what's noted on charts and consent forms. Surgeons arrive to confirm the scheduled surgeries with patients and sign their initials at the correct surgical sites. When patients enter the OR, the circulating nurse asks them to introduce themselves to the surgical team and confirm the procedure they're about to have. Then, during the time out, every member of the surgical team once again confirms the correct surgical site.

During daily morning huddles, the surgical team mentions if patients with the same or similar last names will be undergoing surgery that day so they're more focused than usual in ensuring the correct procedure is performed on the intended patient.

"We warn patients that they'll be asked to repeat their names and confirm their surgical sites multiple times before surgery, and tell them it's done for their safety," says Rhonda Sebastian, MSN, RN, CNOR, clinical director of surgical services at UPMC Horizon and Jameson. "We also never deviate from the process, regardless of the procedures patients are about to have done. Mistakes can happen when the process breaks down."

Excellent communication skills and teamwork play a big part in preventing wrong-site surgeries, says Robert Yonash, RN, CPPS, senior patient safety liaison at the Pennsylvania Patient Safety Authority (PSA). "We urge staff to work as a team and include the patient," he explains. "Though repeatedly asking patients the same questions can irritate them, the constant checks are necessary for error prevention. We need to include their understanding of the procedure being performed."

CLICK TO CONFIRM Patient information and procedure details are entered into UPMC's electronic medical record for staff to reference at each step of the pre-op process.   |  UPMC Jameson
  • Promote transparency. The proper reporting of wrong-site surgeries and near-misses is essential to raising awareness of issues that need to be addressed and learning from mistakes. It was a lack of communication regarding event reporting that initially fueled the creation of the PSA. Mr. Yonash says many facilities in the state didn't communicate openly and constructively about their errors and struggles. The Pennsylvania legislature sought to correct this issue in 2002 as part of the Medical Care Availability and Reduction of Error Act (MCARE).

The legislature authorized the creation of the PSA, which is charged with receiving mandated error reports from facilities, analyzing the data and disseminating the information to help prevent future occurrences. "Pennsylvania was the first state to require the reporting of incidents that have the potential for patient harm, in addition to serious events," says Mr. Yonash.

The objective of reporting involves documenting and acknowledging what led to these incidents as well as providing case studies to other centers on how to prevent never events. It's promising that the rate of national self-reporting has increased in recent years. The Joint Commission says the percentage of self-reported sentinel events rose to 87% in 2017, compared with 62% in 2005, with 95 wrong-patient/site/procedure cases submitted. The Joint Commission estimates that only 2% of all sentinel events are reported nationally.

  • Empower staff. In the past, UPMC Horizon and Jameson operating room nurses received the health system's Speak Up for Patient Safety Award for intervening to prevent wrong-site surgeries, and this year the sister hospitals were winners of this magazine's OR Excellence Award for Patient Safety. They deserve this recognition in more ways than one. Due diligence by staff and leadership in areas of certification, continuing education and patient care have fostered a strong culture of patient safety.

"If staff feel something isn't right or set up correctly, they can call a condition stop and the surgery will not proceed until we resolve the issue," says Ms. Sebastian.

Developing and maintaining a culture of safety was initially a challenge for UPMC Horizon, which acquired UPMC Jameson four years ago. Ms. Sebastian and her staff had to work to unite the two facilities.

Standardization of wrong-site surgery prevention protocols helped create a solid foundation for the union of the two facilities. "Safety is our number one priority for any patient that comes through here for surgery," she says. Her staff are trained to advocate for patients during surgery who are incapable of advocating for themselves.

Near-misses, which happen rarely, show UPMC's safety initiatives have worked correctly. Nurses don't hesitate to speak up if something is wrong. "There is a lot of staff involvement," says Ms. Sebastian. "Empower your staff to speak up and always stand behind them. Let them know that if they stop the line, they won't be punished. They need to know you're going to have their back."

Constructive communication

DOUBLE TAKE Surgical team members at UPMC huddle each morning to preview the day's case schedule and highlight patients with similar-sounding names.   |  UPMC Jameson

UPMC uses a combination of the policies and procedures created by recommending bodies such as the PSA, the World Health Organization and The Joint Commission. On top of staying up to date on the newest safety recommendations, Ms. Sebastian's facilities implement their own safety measures, such as the condition stop, which is practiced throughout the entire UPMC network.

Staff engagement extends beyond clinical members to involve the risk management and legal departments at UPMC. The risk management staff stays in close contact with PSA. Safety liaisons have held in-services, which are mandatory for operating room staff. Officials from the legal department also periodically in-service staff on consents and Ms. Sebastian's team interacts frequently with the PSA.

The PSA's structure as a non-regulatory body, detached from the state department of health, allows it to work with facilities on constructive solutions to safety-related issues without the underlying threat of citation. This arrangement lets PSA maintain confidentiality and work directly with facilities to improve patient care. Ms. Sebastian believes the mandatory reporting of safety incidents in Pennsylvania opens up the lines of communication among facilities, and eliminates the danger of maintaining a sense of secrecy about what happens in the OR.

"Surgical professionals want to do the right thing," says Mr. Yonash. "We want to keep patients safe. Honest communication plays a big part in this. We want everyone to work together and to speak up if something doesn't look right."

Teamwork, transparency, continued education and staff support have created an excellent environment of safety at UPMC Horizon and Jameson, one to be modeled by other facilities looking to improve practices that prevent wrong-site surgery. "Provide a lot of support and education for your staff," says Ms. Sebastian. "It takes time to make change happen. Stay the course — it won't happen overnight." OSM

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