Minnesota Safe Surgery Coalition

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Minnesota Safe Surgery Coalition

• Coalition Goal Eliminate Wrong Site, Wrong
  Procedure and Wrong Patient Events within 3
  Years.
• Members
• Minnesota Hospital Association
• Minnesota Department of Health
• Minnesota Medical Association
• Minnesota Medical Group Management Association
• MMIC Group

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The Minnesota Time Out Campaign

• Phase 1 of the Safe Surgery Project
• Targets Wrong Site Events
• Objective Administration, physicians and
  front-line staff will join together to hold each
  other accountable for conducting robust,
  effective Time Outs for every patient, every
  invasive procedure, every time.
• Kick-off on National Time Out Day (June 15)

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Why is the Campaign Necessary?

• Reports of adverse events involving procedures
  performed on the wrong site/side/level have been
  increasing in Minnesota.
• Last year, 66 of wrong site procedures were on
  the wrong side (right vs. left).

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Sample Minnesota Events 

• The Anesthesia Care Provider inserted the needle
  to perform an anesthesia block.  The patient felt
  a twitch in their leg and stated that the twitch
  was on the left side and the surgery should be on
  the right side. The patient was correct.
• No site marking or Time Out had been performed
  for the block.
• Site mark for right stent placement placed on arm
  and was not visible after prepping and draping.
  Left stent placement performed.
• Site mark was not visualized during the Time Out.

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Sample Minnesota Events 

• Surgeon consulted on patients in two different
  rooms. Surgeon performed knee aspiration on
  incorrect side thinking it was the other patient.
  
• Patient identity was not verified and Time Out
  was not performed.
• Patient consented to left knee arthroscopy.
  Right leg placed in holder and tourniquet
  placed.  Surgical site had been marked but when
  initials were not seen on the right leg surgeon
  thought marked was removed by surgical prep. 
• Site marked was not visualized during the Time
  Out.

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Sample Minnesota Events 

• Patient consent for a right knee arthroscopy.
  All documents indicated right knee and right knee
  was site marked by surgeon. Surgeon and nurse put
  leg holder on left side of table and positioned
  left leg in holder.  Left knee injected, prepped
  and draped.  Time Out conducted and incision made
  to left knee.  When nurse started documentation,
  she noted that the left knee was intended and
  informed the surgeon.  
• Site mark was not visualized during the Time Out.
  All members of the team were not engaged in the
  Time Out process.

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Why Focus on Time-Out?

• Almost all of the 2010 wrong site procedures in
  Minnesota were breakdowns in basic best practices
  - primarily in the Time Out process.
• Observational studies of time out in Minnesota
  ORs show that
• Site mark not visualized
• Source documents not referenced
• Stating I agree rather than independent
  verification
• In a number of instances, such as an anesthesia
  block prior to a surgical procedure, there was no
  process in place to conduct site marking and a
  Time Out.

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Development of MN Time Out

• Developed by University of MN Center for Human
  Factors Research and Design
• Observed 58 procedures across 8 hospitals
• Direct observations
• Focus groups

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Addressing Gaps

• MN Time Out addresses observed gaps
• Uncertainty about initiation
• No cessation of activity
• No acknowledgement of accuracy of information
• No referral to source documents
• No or incorrect site marks
• Team members not cognitively engaged

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Minnesota Time Out
Step Rationale
1. Person performing procedure initiates The team is more likely to cease activity and come together for the Time Out.
2. Team ceases all activity Active listening/participation.
3. Designated staff, other than person performing procedure (OR circulator), verbally states patient name, procedure and location while referring to source documents. (In the OR, ACP also provides patient name and procedure from their documentation). -Surgeon is the last to verify to control for hierarchy/power differential, i.e. if the surgeon states information first, the team is more likely to agree rather than provide independent verification. -Source documents have been verified prior to the procedure and should be an accurate source of information.
4. Designated staff, other than person performing procedure (OR scrub), locates and verbally confirms visualization of site mark and states where it is located. -Providing an active role (rather than I agree) for all team members counters rote recitation. -Team members more likely to be cognitively engaged in the process.
5. Person performing procedure verbally states procedure including location from memory. Decreases memory interference to focus on this procedure.
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Call to Action for Physicians

• All steps of the Time Out must be conducted
  before every invasive procedure for every
  patient, every time.
• Key areas where a Time Out is not consistently
  applied across the state
• OR procedures
• Blocks and injections prior to OR procedures
• Stand alone anesthesia blocks
• Interventional radiology procedures

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Stop the Line Practice

• Any person who observes or becomes aware of
  harmful situation in patient care has the
  authority and responsibility to speak up and
  request the process be stopped in order to
  clarify the patient safety situation.
• This person needs to say in a firm, clear and
  respectful manner STOP, I have a patient safety
  concern.
• Staff are to assertively voice concern at least
  two times to ensure the request has been heard.
• If there is noncompliance to respond to this time
  out, the Chain of Command process is invoked.

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Success stories

• An elderly patient undergoing repair of a hip
  fracture was prepped for a right-sided procedure,
  consistent with the consent, history and
  physical, and a consultation report. During the
  time out, the surgical team determined that the
  patient had a left hip fracture, which was then
  confirmed by x-ray. The procedure was performed
  on the correct side.
• Wrong knee was marked in pre-procedure area.
  Verification of the site marking against source
  documents uncovered the discrepancy and correct
  site was marked and surgery completed.

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Take-Home Points

• A Time Out must be completed prior to any
  invasive procedure across the organization for
  every patient, every time.
• All Time Outs must be completed following the 5
  key steps in the Time Out process.
• If there are any discrepancies during the Time
  Out or a step is not completed, members of the
  team will Stop the Line until resolution and
  agreement by the team.
• Staff and physicians will be supported by
  administration in Stopping the Line.