Nancy & carol fsasc 4 9 15 life lessons safe surgery time out process

3/27/2015

Life Lessons – One Team’s Collaboration to Make a Wrong... Right Safe Surgery Time Out Process Presented by:

Nancy Burden & Carol Hathaway Recognizing the input of Angela Kramer

FSASC Quality & Risk Management Conference April 2015 Renaissance Orlando at SeaWorld

The Problem Wrong site/side surgery • Google search for wrong site surgery reveals 98 million results • Occurs 40-50 times per week in the U.S. (TJC) • 72% had defects in the "Time Out“ (AORN) • #1 OR safety concern and considered “massively under-reported” (TJC) 2

1

3/27/2015

AHRQ referenced study 3

WHY can this happen?

(Analyze data)

• Distractions and rushing during time out • Time out process occurs before all staff ready and paying attention: rote manner, no active thought process • Time out performed without full participation • Time outs do not occur with multiple but separate procedures (AORN)

• Incorrect patient identification process 4

2

3/27/2015

Objectives today After this presentation, participants will be able to:

 Discuss methods to implement/maintain a culture of safety  Define clear roles and responsibilities for the timeout process  Implement consistent, active communication  Describe best practices for a Safe Surgery Time out

5

Best Practice?

We felt that we had a quality time out practice – maybe even Tah Dah??? THE BEST???

 Strong policy  Attestation of compliance on hire by TM and physicians  Ongoing education and orientation  Management and Team Member commitment

6

3

3/27/2015

Patient Safety Time Out Checklist 30” x 60” poster In every OR In line of vision for all team members

For years……………… …………………….

7

The Unspeakable…….

8

4

3/27/2015

The Team…….

Skilled, board certified orthopedic surgeon with Hand Fellowship Experienced OR nurse and surgical tech Anesthesiologist & CRNA with strong skills & experiences

TEAM HAD WORKED TOGETHER FOR OVER 6 YEARS 9

What happened…….

1st hand – trigger finger

2nd hand – trigger finger and carpal tunnel

10

5

3/27/2015

The Unspeakable…….

11

So “guess whose coming to dinner”

PROACTIVE APPROACH: • AHCA report (DOH and BOM down line from AHCA) • Peer Review/Data Bank reporting • Coaching and Counseling • Action Plan for Improvement

12

6

3/27/2015

WHY HERE

during

THIS CASE?

(AND HOW?)

• Similarity of surgical sites & procedures • Limited visualization by team members - closeness of the trigger and carpal sites under drape • Surgeon’s plan in his head – “two on one side, one on the other” • Only one timeout performed 13

NEXT STEPS (Create/implement an action plan) • Code 15 reporting – involving RM • Stakeholder involvement: “safe” debriefing, brainstorming • Clinical team members • Surgeons and Anesthesia Providers • Leadership • Literature & regulations search BOTTOM LINE: What is best practice for patients, team members, and physicians?

14

7

3/27/2015

SPIT IT OUT………….

In a “NO BLAME” Team Environment: • Timeouts occur before physician gowns and gloves • Surgical techs: don’t feel empowered to speak up • Anesthesia personnel are not involved enough • RNs typically feel “no one is listening” • Surgeons express too many variations in time out • Timeouts confused with WHO checklist 15

It’s all about ………..

Bottom line – this was NOT about AHCA or any other outside agency – it was about the quality we should have provided to this man in our care….

BUT DIDN’T

16

8

3/27/2015

The Solution (Implement an action plan)

Safe Surgery Time Out Process • • • • •

Evidence-based Best Practice (Minnesota Time Out) Active cognition Full participation Specific information Six steps must happen for every procedure and every patient, every time 17

Minnesota Time Out • Designed on human factors and cognitive science principles • Actively engages whole team • 23% reduction in wrong site surgery over a 5-year study • ACTIVE, COGNITIVE COMMUNICATION 1.http://www.health.state.mn.us/patientsafety/ae/wsssummaryfs.pdf 2. Rydrych, D, Apold, J and Harder, K. (2012) Preventing wrong-site surgery in Minnesota: a 5-Year Journey. Retrieved at: http://www.psqh.com/novemberdecember-2012

18

9

3/27/2015

Six Key Steps - Minnesota Time out as basis Step 1: The surgeon/proceduralist performing the procedure initiates the time out after gowned and gloved, and after approaching the surgical site.

(FL BOM January 2013)

Step 2: The entire team ceases all non-critical activity.

19

Six Key Steps Step 3: The circulating nurse verbally reads the patient’s name, date of birth, procedure(s), and procedure site(s) from the patient’s signed informed consent.

20

10

3/27/2015

Six Key Steps Step 4: The anesthesia care provider verbally reads the patient’s name and date of birth from the patient’s armband, the procedure(s), and states the antibiotic, dose, and administration status.

21

Six Key Steps Step 5: The scrub tech verbalizes the location of the site marking(s), or area(s) draped if no site marking required, and states procedure(s) set up for.

22

11

3/27/2015

Six Key Steps Step 6: The surgeon performing procedure(s) states the patient’s name and complete procedure(s) from memory and asks for safety concerns.

One standard of care *the highest standard* consistently.

23

PHYSICIAN/STAFF RESPONSE There were some challenges‌

24

12

3/27/2015

THE REAL DEAL…….

BUT THEN THIS HAPPENED insert video

25

Ongoing Communication/Support • Supporting and caring for each other

• ACTIVE listening

2

+ 1

• Consistent communication of specific information • Encourage honest feedback with no blame

26

13

3/27/2015

Ongoing Communication/Support • Online training created –mandatory for ASC team and available throughout the health system – all new hires • Periodic time out audits • Additions to Safe Surgery Checklist (added “verbally” and “all personnel stop” language)

27

Change CAN HAPPEN • Use of evidence-based research • A strong plan • Communication • Periodic follow up Most important – • Supportive and involved leaders

28

14

3/27/2015

And are you wondering about this Patient?

• He actually was to have that 2nd carpal tunnel in near future • Patient totally understanding and continued with same surgeon for future care • No legal action

Lessons learned…….

30

15