All Entries Tagged With: "checklist"
Is preventing wrong-site surgery rocket science?
A very interesting article by Kaiser Health News, in collaboration with The Washington Post, focuses on the fact that despite Universal Protocol®, there is no evidence that wrong-site, wrong-procedure, or wrong-patient surgeries have decreased over the years.
President of Joint Commission Mark Chassin told Kaiser Health News that he’d argue solving the problem “really is rocket science” despite earlier widespread opinion that simple checklists and timeouts would work against mistakes. It seems that it’s not necessarily that checklists and timeouts don’t work; it’s that they exist in a system and culture that is not conducive to using them. Cassin blames, in part, a healthcare system that puts more emphasis on OR turnover than flawless patient safety. Another large part of the problem is cultural, said Peter Provonost, a prominent safety expert and medical director of the Johns Hopkins Center for Innovation in Quality Patient Care. Physicians are not expected nor taught to follow rules like other staff,
The usual comparisons to the aviation industry are also made—unfortunately, the point is made that pilot mistakes are often widely reported as the repercussions are severe, while many fear wrong-site surgeries are still underreported, as there is no public national database.
What do you think? Is it difficult to get surgeons to comply with appropriate time outs and checklists? Would better reporting help? Would more severe monetary repercussions to the hospital or to the surgeon and/or surgical team help? Has something in particular worked well at your hospital? Share your thoughts below.
MGH surgeon goes public with mistake
Today’s issue of The New England Journal of Medicine contains a report about a case in which Massachusetts General Hospital surgeon mistakenly performed the wrong surgery on a patient. The Boston Globe, in its White Coat Notes blog series, discussed the report.
The NEJM report explains how surgeon David Ring performed a carpal-tunnel syndrome relief operation on a a 65-year-old woman who came in for a different type of surgery to relive pain caused by what is commonly referred to as “trigger finger.” In the report, Ring recounts the day when the mistake happened and the cascade of events that preceded the incorrect surgery. The patient was his last of the day, and he said he had three major surgeries and a few minor ones, thinking to himself, according to the report:
My mind-set at the start of the day was, “I have three big procedures that I have specifically planned and prepared for and a few ‘carpal tunnels’ to perform today.
Ring recounts a number of contributing factors, including:
- A surgery unit that was behind schedule
- A last-minute change in ORs
- A change in personnel in the OR, leading to the nurse who performed the preoperative assessment to be absent during the surgery
- A stressful encounter before the surgery in which Ring consoled a patient he had performed a carpal-tunnel surgery earlier in the day
- A nurse who mistook Ring talking to the patient in Spanish as a time out. No formal time out occurred.
- Change of nursing teams during surgery
About 15 minutes after the surgery, Ring realized his mistake and informed all parties. The patient had no adverse events from either surgery.
Does this sound like a typical day to you? Could it happen where you work?
Safety in the surgical environment
Briefings on Patient Safety recently launched a new column that explores patient safety from the perspective of a newcomer to the field. Columnist Catherine Hinz, MHA, is the patient safety lead at HealthEast Care System in St. Paul, MN. Previously, Hinz worked for seven years as an ED health unit coordinator, completed a patient safety internship with the Agency for Healthcare Research and Quality, and finished a residency with The Studer Group.
The Patient Safety Monitor blog will be featuring excerpts of Catherine’s columns on the blog, beginning with the most recent, about finding the fun in patient safety:
One of the first things I did when I started in this role was observe surgical cases. The surgical environment fascinates me for many reasons. In patient safety, the operating room (OR) is often one of the most high-profile areas for an adverse event, such as a wrong-site surgery or retained foreign object. Surgery can change the course of a patient’s disease, condition, and healing process in a matter of hours. The unique team dynamics in surgery consist of an incredible amount of interdependence, differing education levels, hierarchy, and minimal interaction with the patient. Lastly, on a personal level, I have undergone two knee surgeries but remembered very little about the process, although it’s one in which I’m interested. I was excited to see the teams in action.
I originally intended to observe surgical cases for the purpose of paying close attention to our timeout process. Month after month, our audits neared 100% correct completion rates. This rate of success, while not impossible, left questions in my mind about our technique and auditing practices. I likened it to a hand hygiene rate of 100%; it sounds fantastic, but in some ways unbelievable. It was a golden opportunity for me to enter the OR suites and observe, because not many people knew who I was or my position in patient safety. In fact, a lot of teams assumed I was a nursing student (an entirely different and equally intriguing issue).
I quickly tried to learn everything I would need to know about being in the OR suite. I reviewed sterile technique and spoke with our surgical educators about what to expect. I was extremely nervous the first time I entered the OR suite. Staying against the wall (and attempting not to touch anything), I stood with my clipboard, ready to take notes. I was in awe of the amount of skill, talent, and expertise with which our teams completed procedures. It was humbling to watch and wonder about the marvels of healthcare—our methods, our devices, and our pharmaceuticals.
As I watched through my patient safety and human factors lens, I also witnessed opportunities that left our teams and patients susceptible to risk. Some of the breakdowns in communication, readiness of imaging and equipment, and power hierarchies opened the door to innovation and improvement efforts. After a series of weeks observing multiple cases in different facilities, we put a plan together for the year called “All 4 Safe Surgery.” Our four initiatives were:
- A newly revised timeout process utilizing human factors engineering
- An introduction of checklists
- An introduction of briefings
- Collaborative work with the Minnesota Hospital Association for retained foreign objects, called Safe Account
To read Catherine’s full column on safety in the OR, see the July issue of Briefings on Patient Safety (a part of your Patient Safety Monitor subscription for those blog readers out there who are also subscribers.)
Aviation techniques prove to have positive effect on patient safety
Crew Resource Management is not a new topic in healthcare–that is the idea that healthcare as an industry can learn a lot from the aviation industry and many of the concepts used in managing an airplane crew and flight can be used in healthcare to improve patient outcomes. One new study, however, has provided the data to back up this notion, reports American Medical News.
The research, published in the December Archives of Surgery, followed caregivers who had taken a course titled “Lessons from the Cockpit,” which attempts to relate errors in aviation with medical errors and teach how to avoid them. After studying 857 participants of the six-hour course since 2003, researchers concluded that teaching healthcare workers the principles of crew resource management has a positive effect not only on patient care, but on workers’ perception of the culture of safety and self-empowerment.
Some of the most striking results include the use of preoperative checklists (75 % of participants were using them in 2003, and by 2007 100% of participants were using them). Self-initiatied incident reports rose from 709 in the first quarter of 2002 to 1,481 in the first quarter of 2008. However, those involved in the study did conclude that these effects may take years to achieve.
You can read more by checking out the American Medical News article. Although this isn’t really a new idea, I wonder if some larger healthcare systems would take seriously the idea of training all of their staff member in crew resource management.
Lancet op-ed says checklists are good, but not healthcare’s savior
In the past couple of years, much has been made of the use of checklists in the medical field to bring about better patient outcomes and keep patients safe. The most successful project to date that used checklists was the Keystone project in Michigan which used evidence-based methods to sharply reduce the central line infection rate in more than 100 ICUs in that state.
A new op-ed from The Lancet says that while this project showed how a checklist could be used to reduce infection, it was not simply the checklist that accounted for the project’s success. Many other factors worked together with the use of a checklist to reduce the infection rate; since the story was made public through the media, however, most of the project’s success has been attributed to using a checklist. The authors of the op-ed, Charles Bosk, Mary Dixon-Woods, Christine Goeschel, and Peter Pronovost, suggest that using this idea, that checklists are a simple solution to many patient safety problems, actually puts more patients’ safety at risk because of the lack of understanding of the many other factors that made this project a success.
The authors discuss the many factors that were a part of the project’s success: a commitment from each hospital’s leadership team, hours of research and learning on the part of the team leaders identified by hospital leaders, months of meetings to hash out the best plan for moving forward, data collection and reporting on the part of infection control practitioners, and finally the cheklist as a means of keeping team members on track and fostering a good culture of safety.
Additionally, the op-ed’s authors bring up the point that not all problems can be solved even partially by using a checklist–it’s just better suited for some issues and not others.
You can read the full op-ed here (free registration may be required). It’s an interesting take on an idea that’s been well publicized and praised in the past couple of years.
WHO publishes checklist for treating patients with H1N1
Although H1N1 has not been prominently featured on this blog, this checklist from the World Health Organization (WHO) caught my eye because it goes over important infection control and prevention techniques that should be used with every possible H1N1 patient that enters your facility. The WHO Patient Care Checklist: new influenza A (H1N1) released last month by the WHO, can be modified to fit any local practices your facility has also incorporated into treating flu patients. It was tested at facilities around the globe, including Brigham and Women’s Hospital in Boston, MA.
For development of the checklist, the WHO sought advice from experts in:
- infection control
- clinical management of pandemic-prone Influenza
- health care checklists
To read more about the checklist, and to find a version written in Spanish, click here to go to the WHO’s Web site.
CNN is reporting that a vaccine for H1N1 will be made available in the U.S. by October. Today, secretary of health and human services Kathleen Sebelius spoke at a “flu summit” mandated by the Obama administration in an effort to launch a national campaign about H1N1. Experts worry that the flu will spread faster once the fall hits and the normal flu season begins.
To read more about today’s summit, click here.
Has your hospital struggled to prepare for an influx of H1N1 cases? Do you anticipate more training in the future?
Does “ethics checklist” have a place at your hospital?
In the last year, much has been made of the power of checklists. Peter Pronovost and his team from Johns Hopkins succeeded at proving a checklist used in Michigan ICUs helped reduce or prevent central line infection rates. Recently this was replicated in hospitals around the country. The World Health Organization (WHO) Surgical Safety Checklist was proven to reduce surgical errors by one third in operating rooms around the country, and has been incorporated into the IHI’s latest campaign.
Last month the British Medical Journal published a study about a new type of checklist–an ethics checklist. This article in American Medical News provides a more in-depth look at the checklist and uses. Some interesting questions come out of the use of this new checklist, which is currently being piloted at Washington Hospital Center in Washington, D.C. One of these is are checklists becoming an of-the-moment solution for many patient safety concerns?
The American Medical News article contains feedback from both Pronovost and Atul Gawande, director of the WHO initiative. Both agree that checklists alone will not change the behavior of healthcare workers. For specific interventions they have succeeded because of commitments to culture change and an understanding of why the checklist is useful.
The ethics checklist contains items such as ensuring patients’ ideas about treatment , end-0f-life wishes, and family situation/ interactions are all clear. Those who are piloting the checklist are excited about the potential it has to integrate ethics questions more easily into patient care.
