Healthcare Informatics Reply
Active Health Records in Acute Setting DB#8
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Surgery is one area of health care in which preventable medical errors and near misses can occur. However, until the 1999 Institute of Medicine report, To Err Is Human, clinicians were unaware of the number of surgery-associated injuries, deaths, and near misses, because there was no process for recognizing, reporting, and tracking these events (Mulloy, 2008).
The 2015 article written by Nwosu describes two cases from a Nigerian trauma center in which wrong-site surgeries were performed. In case one, a 75-year-old female was injured in a traffic accident. She sustained a central right hip dislocation with an acetabular fracture. During the procedure, the surgeon performed a reduction of the left hip with pin placement. Upon reevaluation, it was discovered that the surgery was performed on the incorrect extremity. Case two involved a 43-year-old bus driver following a traffic accident unable to bear weight bilaterally. Radiographs revealed bilateral femur fractures and a left tibial fracture. Neither incident was officially reported to the hospital for review. Upon analysis of both cases, the surgeon’s inexperience does not play a role in wrong-site surgery error. The factors identified as causes of wrong-site surgeries include distraction, incomplete preoperative assessment, and insufficient patient information in the operating room, policy issues, and the lack of operating room checklists (Nwosu, 2015). In my opinion, both cases were due to a lack of attention to detail and a lack of teamwork and communication, specifically in the second case study. The anesthesiologist brought his concerns to the surgeon’s attention several times without a “time-out” to regroup and ensure the correct procedure was performed.
The Joint Commission (TJC) publishes yearly National Patient Safety Goals. These goals are designed to improve patient safety. The goals focus on problems in health care safety and how to solve them. The 2021 safety goals include several goals, including identifying patients correctly, improving staff communication, using medicines safely, using alarms safely, preventing infection, identifying patient safety risks, and preventing mistakes in surgery (jointcommission.org, 2021). Although all these goals are essential, we will focus on preventing mistakes in surgery for this discussion.
There were two programs described in the article implemented to improve hospital patient safety. The Joint Commission introduced the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery in January 2003. The Universal Protocol applies to all surgical and non-surgical invasive procedures. Evidence indicates that procedures that place the patient at the most risk include general anesthesia or deep sedation, although other procedures may also affect patient safety (jointcommission.org, 2021). Hospitals can enhance safety by correctly identifying the patient, the appropriate procedure, and the procedure’s correct site. The Universal Protocol is implemented most successfully in hospitals with a culture that promotes teamwork and where all individuals feel empowered to protect patient safety. The Universal Protocol is based on the following principles (jointcommission.org, 2021):
· Wrong-person, wrong-site, and wrong-procedure surgery can and must be prevented.
· Using a multiple and complementary strategy to always conduct the correct procedure on the correct person at the correct site.
· Active involvement and the use of effective methods to improve communication among all members of the procedure team are essential for success.
· Patient and family involvement in the process, as much as possible.
· Implementation of a standardized protocol is most effective in achieving safety
Another program designed to reduce surgical errors was the World Health Organization (WHO) Surgical Safety Checklist. The checklist consisted of “sign-in, time-out, and sign-out.” The protocol also promotes safe anesthesia, teamwork, and the prevention of surgical infections (Nwosu, 2015). Unfortunately, in many parts of Africa, Asia, and Europe, as of 2015, the TJC “Universal Protocol” and the “WHO Surgical Site Safety Checklist” were not being utilized.
The registration process must be both accurate and efficient. Failure to meet both of these goals can lead to adverse outcomes. Slow registration can hinder care by delaying the processing of orders of tests or delaying access to existing medical records and, in the long run, not providing adequate emergency care (Hakimzada, 2008). Inaccuracy in gathering information can lead to errors, including lack of access to existing medical records, inability to contact a patient after discharge, and even implementation of an incorrect treatment regimen with dangerous consequences to the patient’s safety.
Biblical integration: John 15:12, “My command is this: Love each other as I have loved you.” God loves us in an incredible way. It’s up to us to find ways to bring that love into our community.
References:
Hakimzada, A. F., Green, R. A., Sayan, O. R., Zhang, J., & Patel, V. L. (2008). The nature and occurrence of registration errors in the emergency department. International journal of medical informatics, 77(3), 169–175. https://doi.org/10.1016/j.ijmedinf.2007.04.011
Hospital: 2021 National Patient Safety Goals. The Joint Commission. Retrieved on March 8, 2021, from https://www.jointcommission.org/standards/national-patient-safety-goals/hospital-national-patient-safety-goals/ .
Mulloy DF, Hughes RG. Wrong-Site Surgery: A Preventable Medical Error. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 36. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2678/ .
Nwosu, A. (2015). The horror of wrong-site surgery continues: report of two cases in a regional trauma centre in Nigeria. Patient Safety in Surgery, 9:6, DOI 10.1186/s13037-014-0053-2.
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16 hours ago
Catherine Spivey
Disc #8
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As a pre-operative and post-operative care nurse, wrong-site surgeries and patient safety protocols surrounding surgery and consent are at the forefront of my everyday practice. In my facility, patients are asked to confirm their identity with their name and date of birth as well as their surgical site by no less than four people prior to transfer to the operating room. The surgeon is also required (when applicable) to mark the site with their initials prior to leaving the pre-operative area. The two cases presented in the article took place in Nigerian hospitals, however these events are present in facilities all over the world. As written in the article, “JCAHO [has] identified risk factors of wrong-site surgery to include emergency cases, physical deformity, multiple surgeons and multiple procedures being performed during a surgical session… root cause analysis [of these events have] implicated distraction factors, incomplete preoperative assessment, non –availability of pertinent information in the operating room, policy issues such as surgical site marking and verification checklist in the operating room” (Nwosu, 2015). The United States has implemented a Universal Protocol since 2004 to mitigate these risk factors and decrease incidence to a rarity. Using accurate and complete information when registering a patient is also imperative, as this information is used to safety check every step of the surgical/operative process.
In a literature review completed in 2015, “the median incidence estimate for wrong-site surgery across 7 US studies reporting general per-procedure estimates was 0.09 vents per 10,000 surgical procedures” (Hempel et al, 2015). The same literature review found that the most frequently reported causes of wrong-site surgery were “communication problems, including miscommunications among staff, missing information that should have been available to the operating room staff, surgical team members not speaking up when they noticed that a procedure targeted the wrong side, and a surgeon ignoring surgical team members who questioned laterality” (Hempel et al, 2015). Communication issues were most frequently cited, “accounting for 21% of the total” (Hempel et al, 2015). In addition to adhering to safety protocols, addressing communication issues amongst surgical teams is vital.
Simulation can be an effective tool in addressing poor communication amongst health team members. Simulation “has [a] demonstrated effectiveness as a method to train practicing nurses for new procedures, communication processes, and both skill-based and non-skill-based techniques” (Aebersold & Tschannen, 2013). Utilizing it to “address miscommunication and other sources of error, especially in the context of team training and systems-based practice” is beneficial to error prevention and communication improvement (Motola et al, 2013). Simulation is a no-risk no-harm situation, which may help team members feel more incline to share their concerns. Empowering team members to speak up as well as training the care team to stop and listen when a concern is raised is beneficial to the overall effectiveness of the team; further contributing to error prevention.
“Open your mouth, judge righteously, defend the rights of the poor and needy” (English Standard Version, 2001, Proverbs 31:9). When patients enter the healthcare system, they put their full trust in the team caring for them. It is imperative that each member of that team feel able to voice their concerns on behalf of the patient, and that their concerns will be heard and investigated.
References
Aebersold, M., & Tschannen, D. (2013). Simulation in nursing practice: The impact on patient
care. The Online Journal of Issues in Nursing, 18(2).
Hempel, S., Maggard-Gibbons, M., Nguyen, D. K., Dawes, A. J., Miake-Lye, I., Beroes, J. M., … & Shekelle, P. G. (2015). Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. JAMA surgery, 150(8), 796-805.
Motola, I., Devine, L. A., Chung, H. S., Sullivan, J. E., & Issenberg, S. B. (2013). Simulation in
healthcare education: a best evidence practical guide. AMEE Guide No. 82. Medical
Teacher, 35(10), e1511-e1530.
Nwosu, A. (2015). The horror of wrong-site surgery continues: report of two cases in a regional trauma centre in Nigeria. Patient safety in surgery, 9(1), 1-4.
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