Positioned to Prevent Wrong-site Surgery

• 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."

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