Patient Safety Fellowship Project Site Identification for Invasive Procedures Actual Practice vs' Po

1
Patient Safety Fellowship ProjectSite
Identification for Invasive Procedures - Actual
Practice vs. Policy

• Kate Lim, MHA, CHE
• Director of Performance Improvement
• Sentara Williamsburg Community Hospital
• May 16, 2003

2
SENTARA HEALTHCARE

• Sentara Williamsburg Community Hospital
• 139-bed acute-care hospital specializing in
  medicine, surgery and obstetrics. The hospital
  also provides complete diagnostic and imaging
  services, cardiac care, a cancer treatment
  center, pediatrics and orthopedics services.
  Other services include home health, emergency
  services and community health education.

3
STATEMENT OF THE PROBLEM

• From 1991 to 2002, there were 13 claims and/or
  lawsuits related to patient safety in the
  operating room.
• Types of lawsuits or claims
• wrong site surgery
• intraocular lens mix-up
• retained foreign bodies
• complications resulting from surgery

4
OBJECTIVES

• Decrease occurrences of adverse events and near
  misses in the operating room.
• Improve communication among caregivers in the
  operating room.
• Institute safe practices in the perioperative
  environment

5
METHODOLOGY

• DEFINE
• Problem statement Variances still exist in
  identifying the correct site and side of surgery.
  Correct site identification prior to any
  invasive procedure is crucial to patient safety
• Goal statement To achieve zero error on site
  identification for every invasive procedure
• Project scope This project covers only surgical
  services department

6
METHODOLOGY

• MEASURE
• Audit actual practice by following patient from
  pre-op holding to the operating room
• Audit tool listed every step in the policy for
  site identification. It is known as the Say It
  Out Loud policy.
• Collect reports on adverse events and near misses
  related to site identification such as consent
  variance

7
(No Transcript)
8
METHODOLOGY

• ANALYZE
• Result shows that the teams do not follow all the
  protocols as written in the policy especially
  during the final part of Say It Out Loud
• Preliminary audit result was given to department
  manager for follow-up action

9
METHODOLOGY

• IMPROVE
• Final audit report was given to Chief Nursing
  Officer, Vice President of Medical Affairs,
  Director of Surgical Services and Clinical
  directors of OR and Ambulatory Surgery Center.
• Clinical director of OR has assigned a staff
  member of central sterile processing to be an
  auditor.
• Continue to track if OR Team has improved in
  complying with the policy.
• Results to be shared with all surgeons during
  Department of Surgery meeting.

10
METHODOLOGY

• CONTROL
• To make sure every team member is re-educated or
  informed about the importance of adherence to
  policy.
• Another audit to be conducted in the later half
  of the year to assess if there is any improvement
  made by the OR team

11
FINDINGS

• Surgeons do come into room to visually inspect
  the site and help out with scrubbing.
• Surgeons do not participate in verbal
  verification with the whole team (Say It Out
  Loud).
• Anesthesiologists also do not participate in site
  verification.
• Nurses and technicians do verify with each other
  when they bring the patient into the OR.

12
FINDINGS

• Consent variances were tracked from June 2002 to
  April 2003.
• 28 reported events of near misses
• 15 related to wrong site, no site in consent
  form
• 5 related to abbreviations used to denote site
• 5 related to procedure variance (different
  procedure written versus verbal verification with
  surgeon)
• 3 related to wrong name, consent not complete or
  not signed

13
IMPLICATIONS

• It is imperative to correctly identify surgical
  site and side. JCAHO has made site
  identification part of safety goals I and IV.
  Sentara Healthcare has also made it a corporate
  patient safety indicator.
• Marking of site should be the responsibility of
  surgeon prior to sedation and transportation to
  the OR to reduce confusion and handoffs.
• Continue to educate nurses and physicians on the
  need to adhere strictly to protocol.
• Continue with audit process to heighten awareness
  that there is zero tolerance for wrong site
  surgery.

14
CONCLUSION

• A policy can be well written to provide stopgaps
  in the steps and to prevent errors but in actual
  practice, most practitioners do not follow the
  steps as per the written policy.
• Another audit will be conducted in the later half
  of the year to assess if there is any improvement
  in following the protocol.

15
LIMITATIONS

• Surgeons are independent practitioners and it is
  difficult to enforce the policy if they do not
  buy into the process.
• However, the physician leaders are keen to
  monitor this patient safety indicator and
  physician peer review groups are investigating
  every near miss event.