All Entries Tagged With: "Surgical safety"
AHAP Conference opportunities
The Association for Healthcare Accreditation Professionals (AHAP) is hosting its 6th Annual Conference May 10, 2012 – May 11, 2012 in Orlando, FL. It offers so many amazing opportunities to save money, get expert advice, and show off your hospital a bit. I should also note that if you’re one of the first 50 paid registrants you’ll receive a free full-day ticket to any Walt Disney World® Theme Park*! Download the online brochure to learn more.
So what is it and why am I talking about it? The 6th Annual AHAP Conference brings together survey professionals from across the country to discuss solutions and best practices to achieve continual survey readiness and compliance with ever-changing standards and regulations.
What are the opportunities?
- Accreditation Specialist Boot Camp.
- Presentation of the first annual Accreditation Professional of the Year award
- Unique roundtable discussion with representatives from HFAP, DNV, the American Heart Association, and The Joint Commission
- Exciting new poster event featuring research and best practices from your peers. Find out how to submit a poster and save 50% on your registration.
- Learn about:
- Regulatory changes in 2012 and top RFIs: Staying ahead of The Joint Commission and CMS
- What accreditation professionals need to know about Life Safety Code®
- To certify or not to certify? Seeking The Joint Commission disease-specific certifications
- Making the switch from The Joint Commission to DNV: One hospital’s experience with both surveys
- Understanding tracer methodology and the survey process
- A practical approach to policy management
- Suicide Risk: Solutions to rapid assessment, Environment of Care, and documentation issues
- Understanding hospital recognition programs for optimal cardiovascular and stroke care
*Offer ends March 8th.
Top 10 most read blogs posts from 2011
The new year is upon us. I thought before we dive into what’s to come for patient safety and quality in 2012, we might want to look back at 2011 and see what grabbed the attention of the patient safety world.I calculated the top ten by how many times each post was viewed. They are:
10. Joint Commission and FDA to focus on alarm fatigue
The Joint Commission (TJC) told The Boston Globe that it would work with the Food and Drug Administration (FDA) to make alarm fatigue—a worrisome problem in most hospitals—a priority.
9. Disruptive behavior, negligence, endangered patients, and millions of dollars
In August, settlements for old patient safety incidents in Boston and recent investigations in Dallas found more recent patient safety infarctions.
8. Rewarding near-miss reporting
This post discusses the importance–and challenge–of getting staff to report near misses, highlighting an example in one surgical suite in Johns Hopkins Hospital in Baltimore that implemented its Good Catch Awards.
7. Joint Commission issues Sentinel Event Alert about workplace violence
The Joint Commission issued an alert on workplace violence in July 2010, but workplace violence was a hot enough topic to remain at the top in 2011.
My personal story of a patient and family whose anger and frustration grew as they faced an elusive plan of care and a care team who seemed uncommunicative.
5. New York Times article exposes radiation therapy errors
Another post that was published in 2010, but the issue of radiation errors and over-radiation remained hot in 2011. This post highlights one of the first articles in a series The New York Times ran from 2010 and into 2011 on radiation concerns.
4. Medication error prompts lawsuit for Massachusetts General Hospital
A medication error that resulted in a death and a lawsuit was met with a communicative response from hospital representatives, who said systematic improvements implemented since the error now help staff to avoid making similar errors.
3. Boston hospital admits three spinal surgery errors in two months
Published at the very end of 2010, this is yet another post on a hospital admitting to errors—this time surgical site errors—that did not need to happen. Beth Israel Deaconess Medical Center in Boston is in the spotlight after its surgeons made errors in three separate spinal operations in two months.
This post explaining how a resident failed to carry out an order on her mobile device after she was interrupted by a personal text messaged grabbed the attention of Patient Safety Blog readers. With this anecdote as proof, social media concerns have leaped from HIPAA violations to immediate threats to patient safety.
1. Can a video really help curb infections?
Perhaps videos are just more fun to watch. This post embedded the winning video of the APIC Infection Prevention Film Festival, which lays blame on frontline providers who fail to do everything they can to “do no harm—” in this case, failing to wash their hands.
What do you think? Any of your favorites missing? Let me know.
Sentinel events for first half of 2011 available
The November issue of The Joint Commission’s Perspectives gives us an idea of the sentinel events that resulted in death or major permanent loss of function in the beginning half of 2011. This includes 76 incidents of foreign body left after surgery, 67 reports of wrong-patient, wrong-site, or wrong-procedure surgery.
That seems like a lot to me in just six months (especially the wrong-site surgeries).
One other stat that surprised me was 23 criminal events. Perhaps I am just naïve, or maybe there’s just more reporting?
What do you think of these numbers? Do you think it is accurate and unsurprising? Share your thoughts below.
Surgical standardization a takeaway from AHA Leadership Summit
HealthLeaders Media reporter Cheryl Clark attended the American Hospital Association’s Leadership summit and found seven interesting points of focus. One in particular was that surgical prep is becoming more standardized.
The Cleveland Clinic now has nurses doing the surgical prep, who are all trained to do it the same way, using the same materials, to help reduce infection and confusion. Guido Bergomi, director of Project Management of the Quality and Patient Safety Institute of the Cleveland Clinic said he found surgeons were not standardized enough in their prep.
What do you think? Should nurses, formally trained, perform this task? Comment below.
TJC on wrong-site surgery: Count risks, not events
Yesterday, The Joint Commission’s Center for Transforming Healthcare had a live news conference to feature the participants of the Center’s Wrong Site Surgery Project. Largely viewed as a never event, wrong-site surgery may actually be occurring at an estimated 40 times per week, according to The Joint Commission.
Three hospitals/hospital systems and three ambulatory surgery centers discussed their efforts and successes in thwarting the dreaded mistakes—including Mary Reich Cooper, MD, JD, senior vice president and chief quality officer for Lifespan Corporation in Providence, RI. Lifespan includes Rhode Island Hospital, which notoriously had a number of public wrong-site surgeries all within a few years. Cooper says Lifespan eventually installed cameras in the ORs for future auditing and quality improvement, as well as shut down its ORs for an entire day to train staff on new protocol. New staff are subjected to strict orientation as well. They have not had a wrong-site event in the three years since new protocol were implemented, she said.
A few good points were brought up during the call. One is the fundamental understanding that every hospital thinks its protocol works because a wrong-site surgery event hasn’t occurred. However, Mark Chassin, MD, FACP, MPP, MPH, president of The Joint Commission, was quick to point out that these events are relatively rare; therefore, hospitals should count the amount of risks for an event to happen, not the amount of events. Good point—I’m sure most hospitals that have suffered an event didn’t think they were at much risk for one.
Although speakers on the call emphasized that there is no one quick fix, and that each hospital must conduct their own risk assessments to determine weaknesses, there were a couple items that stuck out:
- Surgical scheduling areas need to have a standardized system to collect all patient information, especially patient identification
- Site marking needs to be done using a marker that will not wash off during surgical prep, and no marker that does not meet this standard should be in the room in which site marking occurs. Site marking also needs to be close to incision site, and it’s a good idea to ensure that time outs confirm the mark can be seen after draping.
- Types of surgeries most at-risk include orthopedics, spinal, ophthalmology. Any time multiple surgeries are conducted one after the other on the same patient also creates a higher risk.
Thoughts? Is this a topic your hospital addresses often?
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.
Surgical site infection data not affected by the Surgical Care Improvement Program
A five-year study presented at the American Surgical Association’s annual meeting in early April found that surgical site infection rates remained stable at 6.2%, although compliance with the Surgical Care Improvement Program (SCIP) increased.
SCIP began as an initiative by CMS and the Centers for Disease Control & Prevention (CDC), to provide education on surgical care improvement.
Researchers looked at 61,099 surgeries at 112 Veteran Affairs hospitals from 2005 to 2009, according to the abstract. Five SCIP measures were linked to the VA Surgical Quality Improvement Program (VASQIP) surgical site infection (SSI) data, and researchers found that none of the measures were associated with decreased odds of SSIs. The data was adjusted for risk index and procedure type. The researchers concluded that adherence to SCIP measures was not associated with a reduced occurrence of SSIs.
Day after drinking, surgeons make more mistakes
Keeping patients safe in the OR requires a set of checks: Have we verified the patient, surgery, and site? Is the patient draped appropriately? Do we have all necessary instruments and blood available? How many drinks did the surgeon have at dinner last night?
Don’t recognize that last question as part of the protocol? Perhaps it should be. A new study suggests surgeons make more errors during a day in which they had drunk the night before.
The study, published in the Archives of Surgery, certainly sounds like a fun study –or at least the first half does. Researchers took six surgeons with laparoscopic experience to dinner and offered unlimited amounts of free alcohol, telling them to drink until they felt intoxicated.
According to the Los Angeles Times, researchers drove the surgeons home and picked them up bright and early the next morning to test their laparoscopic surgery skills on a virtual simulator at 9 a.m., 1 p.m, and 4 p.m. Each test produced worse results than their baseline results. The study’s researchers concluded that excessive consumption of alcohol appeared to degrade surgical performance the following day, even at 4 p.m., and said this suggests the need for defined recommendations for alcohol consumption the night before surgeries.
What do you think? Is this is a concern?
Objects left inside patients during surgery coded incorrectly
The Centers for Medicare & Medicaid Services (CMS) last week released data about hospital-acquired conditions (HAC) that was reported by participating hospitals.
However, the data isn’t entirely accurate because some of the coding was done incorrectly, making it more complicated. A total of 18 Illinois hospitals reported objects left inside patients, but didn’t report coding issues, reported The Chicago Tribune.
In three cases at Advocate Christ Medical Center in Oak Lawn, IL, foreign objects left in patients were coded incorrectly. A screw tip broke off during a hip surgery and a catheter tip broke off during a separate procedure; both were supposed to be listed as “mechanical complication of a device,” but were not, according to the Tribune. In a third instance, a sealant that was used in a previous procedure was found by a surgeon, but it was coded incorrectly.
At the University of Illinois at Chicago Medical Center, a device object used to drain a wound was coded incorrectly as a foreign object where it should have been a mechanical complication code because it broke during removal, according to the article.
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?
