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
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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
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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
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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
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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…….
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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
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The Unspeakable…….
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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
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WHY HERE
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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
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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
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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
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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.
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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.
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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.
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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
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THE REAL DEAL…….
BUT THEN THIS HAPPENED insert video
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Ongoing Communication/Support • Supporting and caring for each other
• ACTIVE listening
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• Consistent communication of specific information • Encourage honest feedback with no blame
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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)
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Change CAN HAPPEN • Use of evidence-based research • A strong plan • Communication • Periodic follow up Most important – • Supportive and involved leaders
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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…….
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