Battling Wrong Site Surgery Rhonda L. Anders, MSM, BSN, RN, CNOR, NE-BC Director, Perioperative...

Battling Wrong Site Surgery

Rhonda L. Anders, MSM, BSN, RN, CNOR, NE-BCDirector, Perioperative Services Franciscan St. Francis Health Indianapolis, IN

November 18, 2013

Rhonda Anders, MSM,BSN,RN,CNOR,NEBC

RHONDA ANDERS HAS BEEN A PERIOPERATIVE REGISTERED NURSE FOR 23 YEARS AND HAS FULFILLED THE FOLLOWING ROLES: STAFF NURSE, CLINICAL EDUCATOR, CLINICAL MANAGER, AND PERIOPERATIVE SERVICES DIRECTOR. AS SHE PROGRESSED THROUGH THE VARIOUS STAGES OF HER CAREER, SHE RELIED MORE HEAVILY ON EVIDENCE-BASED PRACTICE AND ENGAGEMENT WITH AORN. SHE SERVED AORN ON THE NATIONAL BOARD OF DIRECTORS FROM MARCH 2007 – MARCH 2011. SHE HAS PREPARED AND PRESENTED DOZENS OF EVIDENCE-BASED PRESENTATIONS RELATED TO SAFETY IN THE PERIOPERATIVE SETTING.

Disclosure Information

AORN’s policy is that the subject matter experts for this product must disclose any financial relationship in a company providing grant funds and/or a company whose product(s) may be discussed or used during the educational activity. Financial disclosure will include the name of the company and/or product and the type of financial relationship, and includes relationships that are in place at the time of the activity or were in place in the 12 months preceding the activity.  Disclosures for this activity are indicated according to the following numeric categories:

1.Consultant/Speaker’s Bureau:

2.Employee

3.Stockholder

4. Product Designer

5.Grant/Research Support :

6.Other relationship (specify) :

7. Has no financial interest: None

Speaker: Rhonda Anders, MSM,BSN,RN,CNOR,NEBC

Discloses no conflict

Accreditation StatementAORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019.

AORN IS PLEASED TO PROVIDE THIS WEBINAR ON THIS IMPORTANT TOPIC. HOWEVER, THE VIEWS EXPRESSED IN THIS WEBINAR ARE THOSE OF THE PRESENTERS AND DO NOT NECESSARILY REPRESENT THE

VIEWS OF, AND SHOULD NOT BE ATTRIBUTED TO AORN.

Planning Committee: Ellice Mellinger MS, BSN, RN, CNOR

Discloses no conflict

4

Learning Objectives

• Catalogue early attempts at preventing wrong site surgery

• Analyze the impact of culture on wrong site surgery

• Compose tactics for the prevention of wrong site surgery

Battling Wrong Site Surgery

Introducing Time Outs:Our Primary Weapon

January 2003 National Patient Safety Goals

1. To improve the accuracy of patient identification by using two patient identifiers and a time out procedure before invasive procedures

2. To eliminate wrong-site, wrong-patient, and wrong procedure surgery using a preoperative verification process to confirm documents, and to implement a process to mark the surgical site and involve the patient/family

Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries. AORN Connections, 5-6

The Joint Commission 2004Universal Protocol for Preventing Wrong

Site, Wrong Procedure, and Wrong Person Surgery

Key Defenses in the Battle:

The Time Out

Preoperative Verification Process

Marking of the Operative Site

Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries. AORN Connections, 5-6

AORN’s 2004 Contributionsto the Battle

Correct Site Surgery Tool Kit National Time Out Day

Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries. AORN Connections, 5-6.

TJC’s Center for Transforming Healthcare Adds to Our Arsenal

2009 Wrong Site Surgery Project

Booking Errors

Verification Errors

Errors Caused by Distracting or Rushing

Elements of the time out not verbalized

Inconsistent Site Marking

Lack of a Fully Functioning Safety Culture

Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries. AORN Connections, 5-6

Targeted Solutions Tool for Wrong Site Surgery

February 2012 Developed from Findings of the Wrong Site Surgery Project:

Guides healthcare providers through a step-by-step process to assess their vulnerabilities

Risk begins as the case is booked due to variations in processes

Identifies specific risk factors unique to each organization

http://www.centerfortransforminghealthcare.org/

DeJohn, P. (2012). Joint Commission tools to prevent wrong surgery. OR Manager, 1-3.

All These Weapons Have Reduced Wrong Site Surgery in the United States

False

US Department of Energy (DOE)Guiding Principles of Safety

Leadership Commitment is Essential for Creating a Culture of Safety

• Senior managers demonstrate their commitment to safety in both word and action

• Patient safety leadership walk rounds

• Safety Attitudes Questionnaire

Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.

Safety Attitudes Questionnaire

Courtesy of Pascal Metrics, Inc. 2013.

US Department of EnergyGuiding Principles of Safety

Everyone is Responsible for Safety• Regardless of position or level within the

organization, everyone must be empowered to raise safety issues or question an action that compromises safety

• The ability of staff to raise concerns influences safety

Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.

Safety Attitudes Questionnaire

Courtesy of Pascal Metrics, Inc. 2013.

US Department of EnergyGuiding Principles of Safety

Empower Governing Bodies to Create and Enforce Safety Policies

Defense Nuclear Facilities Safety Board (1988)

Congress charged this independent oversight organization to develop

meaningful safety standards

ensure consistent requirements for management and contractors

raise technical competence to ensure protection of workers and the public

Created industry wide process to review, identify, and prevent hazards and share best practices to improve safety

Agency for Healthcare Research and Quality (AHRQ)

Called for a single national healthcare safety body to coordinate standards and deliver widespread communication regarding safer health care policies

Tubing and catheter connection errors: brought forth the need to standardize safety approaches with connections

Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.

US Department of EnergySafety Standards

Eliminate Preventable Harm

• Injuries are preventable

• DOE sets the safety goal to ZERO

• Injuries, events, and accidents are not tolerated

• Learning mentality for prevention and improvement-involves critique, investigation and correction.

Identified In Progress Resolved

Defect, or near miss identified by front line staff, dated, and placed on this section of the Learning Board

Identified issues placed here when “who” is assigned to address

When the issue is resolved, or problem solved, it is placed here along with a date of completion

Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.

Learning Board in Action

Identified In Progress Resolved

Patient stated, “Total Hysterectomy” while consent stated, “Vaginal Hysterectomy”. No mention of Salping-oopherectomy. What is the meaning of Total Hysterectomy to a patient? Is this a wrong procedure about to occur?

Assigned to Quality Manager and OR Manager to determine how to incorporate patients’ verbiage into consent forms to assure that what they believe is about to occur is congruent with what the OR team believes is about to occur.

Consent re-designed to prompt additional dialogue free of medical jargon. New consent stresses the importance of understanding what the procedure is in the patients’ own words.

New Language in Consents

•Authorization For and Consent to Surgical Operations, Diagnostic and Therapeutic Procedures

•Doctor/or designee should write proposed procedure here in the patient’s own words

•Please tell me, in your own words, the proposed procedure you are having: ________________________________________________________________________________________

Learning Board Fighting Wrong Site Surgery at All Levels

Identified In Progress Resolved

Case was scheduled as “left carpel tunnel decompression”. It should have been scheduled as “left carpel tunnel decompression, left cubital tunnel release”.

Assigned to Surgery Scheduling Supervisor. Explore documentation of request from Dr. X’s office, examine processes to determine where defect occurred.

Establish a Universal, Uniform Approach for Safety Management

• Integrate safety into all facets of work planning and practices.

• Hazards must be understood with preventative controls in place before engaging in any activity

• Clear and unambiguous roles and responsibilities are established for ensuing safety.

• Use of Checklists

Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.

US Department of EnergyGuiding Principles of Safety

Mandate Reporting of Safety Issues,

Errors and Near Misses

• DOE views front line staff as most important resource for preventing and reporting hazards and potentially unsafe practices

• An effective reporting culture encourages and maintains employees’ open expression of concerns with no fear of retaliation

Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.

Mandate Reporting of Safety Issues, Errors and Near Misses Continued

• Near misses signal system weaknesses, and because harm did not occur, may provide insight into solutions

• Although the national Patient Safety Quality and Improvement Act of 2005 provides confidentiality for reports of medical errors to accredited patient safety organizations, only 27 states require hospitals and/or other medical facilities to report serious medical errors

Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.

Identifying Weakness

• Repeated reports of missing instruments and instrument set sheet not matching actual contents

• Repeated reports of missing indicators in sets

• Reports of incorrect packaging for peel packs

TROUBLE IN CENTRAL STERILE PROCESSING (CSP)!

Taking Action Before Harm• Reviewed hours worked by CSP staff

- No one with less than 90 hours pay for last 3 pay periods.

- One employee at 153 hours / pay

• Implemented instrument tracking system

- required the updating of all set sheets

- gives us the ability to identify where defects occur in the process

• Added annual mandatory training

- to review sterilization indicators and peel packs that go with the different methods of sterilization

US Department of EnergyGuiding Principles of SafetyCultivate Learning as Part of the Organizational Mentality

Open trusting environment

Focus on injury prevention

Front line staff freely question processes

Sense of ownership for improving the workplace

Mechanisms such as occurrence reporting, incident investigation, root cause analysis, and self assessments contribute to the learning process.

Medical simulation enhancing learning cultures across healthcare continuum

Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.

Four Components to the Briefing

Everyone knows the game plan

Psychological safety is ensured

Norms of conduct are discussed

Expectation of excellence is set

Berenholtz, S., Schumacher, K., Hayanga, A., Simon, M., Goeschel, C., Pronovost, P., et al. (2009). Implementing standardized operating room briefings and debriefings at a large regional medical center. Joint Commission Journal on Quality and Patient Safety, 391-397.

The BriefingCreating Connection with the Patient

Is it the gallbladder in room 9….or…

Is it…Our patient Rhonda Anders,

- 46-year old female

- Recent history of tibial plateau fracture followed by a series of Deep Vein Thrombosis (DVT)

- Currently taking 6 mg of Coumadin daily with an INR of 2.6

- She’s showing signs of sepsis so we’ve got to get her gallbladder out today

- I have no special equipment or instrument needs

- But does this information raise questions for any of you?

The BriefingCreating Connection as a Team

Surgeon: “Hey guys.”

Staff: “Good morning Dr. Mandelbaum.”

Anesthesiologist, “Hey Jon, how was your trip to Florida last week?”

New employee scrubbed in but never introduced…

Or…

Surgeon: “Hey guys.”

RN Circulator: “Good morning Dr. Mandelbaum. This is Stacy Wilson. She’s a new nurse with us at St. Francis, but not new to the OR”

Stacy RN: “I’ve been in the OR for the past 12 years. Nice to meet you”

Anesthesiologist: “You used to work at Methodist, didn’t you? I thought I recognized you”

Dr. Mandelbaum: “If any of our equipment or supplies look foreign to you, be sure to ask your preceptor or me for information”

Debriefing is the element that links

teamwork and improvement

Berenholtz, S., Schumacher, K., Hayanga, A., Simon, M., Goeschel, C., Pronovost, P., et al. (2009). Implementing standardized operating room briefings and debriefings at a large regional medical center. Joint Commission Journal on Quality and Patient Safety, 391-397.

The DebriefingCreating a Learning Organization

Surgeon: “Thanks everybody. Go ahead and get the next patient into the room as soon as you can. I’m going over to 3 West for a few minutes to round.”

Staff: “Okay, we’ll page you when the patient is in the room.”

Anesthesiologist: “See you in about 20 minutes, okay…?”

Or…

RN Circulator: “Let’s do the debriefing now. What went well today?”

Surgeon: “Everything from my perspective, you guys did a great job, thanks. Stacy, nice job! Was there anything you would have liked to have been different?”

Scrub: “The lap chole set had a hole in the wrapper. Can you write up a defect sheet and request that this set go into a rigid container.”

RN Circulator: “Will do. Is there anything we should do differently next time?”

New Staff Member Stacy RN: “Yes, I didn’t know Dr. Mandelbaum’s special instruments. I felt like I was fumbling. Can you go over those with me before the next case.”

Communicate ClearlyThe Least Expensive Weapon!

Structured Communication

SBAR

Situation

Background

Assessment

Recommendation

Repeat Back

Structured Critical Language

Critical LanguageA Phrase That Stops the Work

• “I need a little clarity”

• “I am concerned”

• “I am unclear”

• “This is unsafe”

Stopping the WorkSurgery Attendant (SA) arrives at entrance doors to room 12 with patient.

The RN Circulator sees the patient and says, “Stop! I have a concern I need to address.”

To SA and Patient, the RN Circulator says: “I’ll be right out to explain.”

•Rooms 12 and 14 were doing Total Joint Jump Rooms

•Room 14’s patient was about to be brought into Room 12

•They were both having total hip replacements, but on different sides. What if…

Environment Rife with Embarrassment orPsychological Safety

Psychological Safety:

A belief that one will not be humiliated or punished for speaking up with ideas, questions, concerns, or mistakes

A shared sense of psychological safety is a critical element in an effective learning system

Embarrass:Feel self-conscious or ill at easeHave your composure disturbedFeel uncomfortable because of shame or wounded pride

Edmondson, A. (1996). Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, 350-383.

Do You Have to ProtectYour Image at Work?

• Edmondson, A. (1996). Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, 350-383.

• Don’t ask questions

• Don’t ask for feedback on your performance

• Don’t look doubtful or criticize

• Don’t suggest anything innovative

To Protect One’s Image: If you don’t want to look… STUPID

INCOMPETENT

NEGATIVE

DISRUPTIVE

Stupid

Incompetent

Negative

Disruptive

Psychological Safety to Question the Status Quo

• Ask Questions

• Ask for Feedback

• Be Doubtful

• Be InnovativePsych

ological

Safety

Edmondson, A. (1996). Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, 350-383.

The Fight Continues…Use ALL Weapons at Your Disposal

Time OutPreop Verification

Site MarkingChecklists

CSS Tool KitNational Time Out

DayTargeted Solutions

Tool

BriefingSkilled

CommunicationDebriefing

Learning CulturePsychological

Safety

References

Berenholtz, S., Schumacher, K., Hayanga, A., Simon, M., Goeschel, C., Pronovost, P., et al. (2009). Implementing standardized operating room briefings and debriefings at a large regional medical center. Joint Commission Journal on Quality and Patient Safety, 391-397.

Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.

DeJohn, P. (2012). Joint Commission tools to prevent wrong surgery. OR Manager, 1-3.

Edmondson, A. (1996). Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, 350-383.

Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries. AORN Connections, 5-6.

Pascal Metrics, Inc. 2013

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