Case records of The Massachusetts General Hospital: Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand

AOA Critical Issues: A Culture of Safety Across All Orthopaedic Professional Endeavors

ABSTRACT

Medical professionals strive for a culture of safety in which error is anticipated, systems are designed to catch an error before it causes harm, and each event is an opportunity for specific clinicians and the system they work in to improve. A culture of safety is based on behavioral ethics, which recognizes that the automatic functions of the human mind can lead good people to misstep, and it incorporates tools such as checklists that embody critical thinking in order to help limit missteps and associated harm. Although the discussion surrounding a culture of safety often focuses on patient care, the social contract between physicians and society involves expectations that physicians will use their expertise to promote the public good in all of their professional endeavors. For example, lapses in professional conduct in the management of conflicts of interest and in ethical marketing have led to restrictions in physician self-regulation. Orthopaedic surgeons can cultivate a culture of safety and a growth mindset across all aspects of the profession, including media coverage of musculoskeletal illness, surgeon participation in informational media (e.g., podcasts and blogs), the marketing of oneself or one's practice, practice patterns and variations, academic discourse, expert legal testimony, the development and implementation of policy and law, and commercial ventures. Systems that anticipate the human potential for missteps; create tools, tactics, and structures to limit missteps and associated harm; and support surgeons and their teams in all professional endeavors can contribute to the effective and fulfilling promotion of the public good.

Surgical complications: errors and adverse events

Complications are a recognized hazard of surgery. The term is confusing; it has multiple meanings, including surgical error and adverse surgical outcomes. I propose the latter two terms are used. Grading of 'complications' is difficult but made easier by grading errors and outcomes separately, though they are not always linked. The exact grades are not established.Error avoidance requires efforts at a personal (surgeon) level, including training, learning and preparation, and at a systems level. Understanding human factors is important.The perspective of patients about adverse outcomes is not well understood. There is evidence that, unsurprisingly, patient perspectives may be different to surgeon perspectives. There are a range of surgeon responses to error and adverse outcomes; many are negative. These need to be understood better in order to protect patients and surgeons in the immediate aftermath and in the potentially prolonged 'recovery time', both for patients and surgeons.Level of evidence: V.

Characteristics of Cancer Hospitals with Written Language Access Policies

Patients with limited English proficiency receive worse care due to communication barriers. Little is known about which cancer hospitals have written language access policies addressing bilingual clinicians. We conducted a cross-sectional survey of healthcare organizations, matching survey data to American Hospital Association Survey and American Community Survey data. We analyzed characteristics associated with hospitals having bilingual clinician policies. The response rate was 71% (127/178). Many hospitals (53 [42%]) did not have written policies on bilingual clinicians. Having bilingual clinicians available at the hospital was associated with having a written policy on bilingual clinicians, while being an NCORP site was associated with not having a written policy on bilingual clinicians. Patient demographic characteristics were not associated with hospitals having written policies on bilingual clinicians. A substantial proportion of cancer hospitals do not have policies that cover language use by bilingual clinicians, particularly at NCORP sites. Having written policies on bilingual clinicians has the potential to mitigate cancer disparities by facilitating accountability, improving communication, and reducing errors.

Conducting Safety Research Safely: A Policy-Based Approach for Conducting Research with Peer Review Protected Material

A multidisciplinary team developed a policy-based approach that provides guidance for using peer review protected information for safety research while maintaining peer review privilege. The approach includes project approval by an ad hoc review committee, signed confidentiality agreements by investigators and study staff, early removal of case identification numbers, standards for maintaining data security, and publication of aggregate data without data set sharing. By describing this procedure and embedding into an institutional policy on Data for Performance Improvement, the team encourages other institutions to develop similar policies consistent with their state regulations.

Comparing the sterility and visibility of surgical marking pens available in Australia

BACKGROUND

Surgical site marking is an important safety procedure prior to surgery. Visibility of pen marks is affected by surgical wash which increases the risk of wrong-site surgery. Additionally, multiple patient contact with a single pen is a potential source of bacterial transmission. In this study we compare pens commonly used for surgical marking in Australia.

METHODS

We conducted an unblinded, prospective cohort study comparing 12 marking pens. Six volunteers' thighs were marked with each pen. Standardized photographs were taken before and after wash with four prep solutions. Ink visibility was analysed using grayscale images, comparing the pen mark tone before and after wash. The pen tips were swabbed for culture.

RESULTS

Red tinted 2% chlorhexidine gluconate (w/v) with 70% isopropyl alcohol (v/v) was shown to reduce pen mark visibility significantly more than the other solutions used. The Pentel N50 permanent marker and Aspen WriteSite Plus were least affected by wash. No pen tip cultured any bacteria.

CONCLUSIONS

When marking the correct site for surgery, we recommend the use of either the Pentel N50 permanent marker or Aspen Writesite Plus pen. A 2-min interval between patient contact limits bacterial transmission.

Safety in Hand Surgery: Eliminating Wrong-Site Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the definition of wrong-site surgery and what it may encompass. 2. State the causes of wrong-site hand surgery. 3. Give examples of initiatives used to prevent wrong-site surgery. 4. Describe a process to minimize the risk of performing wrong-site surgery.

SUMMARY

Wrong-site surgery remains a problem in our ever-evolving culture of surgical safety, and hand surgeons are at particularly high risk. Broadly speaking, wrong-site surgery is a procedure performed at an incorrect anatomical site. In hand surgery, this includes errors in laterality, wrong digit(s), wrong procedure(s), or even a failure to complete all indicated procedures. This article examines the scope of this safety issue, the current challenges to preventing wrong-site surgery, and the authors' proposed solutions to eliminating wrong-site surgery and establishing a culture of safety in hand surgery.

Safer paediatric surgical teams: A 5-year evaluation of crew resource management implementation and outcomes

Objective

Evaluate longitudinal changes in technical and non-technical skills (teamwork, situation monitoring, communication and leadership), safety culture, and clinical outcomes before and after implementation of a crew resource management (CRM) safety program.

Design

A multi-level prospective single case study in accordance with the SQUIRE-guidelines for reporting quality improvement efforts.

Setting

Large university paediatric surgical service.

Participant(s)

All 153 managers and staff.

Interventions

Training of staff in CRM, systematic risk assessments, and the redesign of work practices captured and reinforced through the development, implementation and refinement of SOPs.

Main Outcome Measure(s)

Data were collected related to: 1) Relevance of CRM training (survey), 2) Safety culture (survey), 3) Team behaviours in clinical practice (non-participatory observations with MedPACT protocol) and 4) Effects on perioperative care for laparoscopic appendectomies-a representative and frequently performed surgical procedure (electronic medical records and administrative data for length of stay, unplanned readmissions and returns to the Operating Room).

Results

Non-technical skills, the use of safety tools, as well as adherence to guidelines for appendectomies all improved significantly over time. Significant safety culture improvements were found in teamwork across and within units, supervisors' expectations and actions, non-punitive response to adverse events, and perceptions of overall patient safety. Unplanned readmissions following appendectomy declined significantly.

Conclusions

Implementation of a comprehensive CRM program including associated safety tools created sustained adherence to new work practices and improved non-technical and technical skills, surgical outcomes and safety culture.

Effectiveness of Surgical Safety Checklists in Improving Patient Safety

Wrong-site surgery is all too common. Despite more than a decade of campaigns by major organizations to prevent these events, there are still reports of such mistakes. This article reviews the recent literature on surgical safety checklists and other tools designed to prevent wrong-site surgery and improve patient safety in the operating room. Emphasis is placed on how well institutions comply with these guidelines, the perceptions and attitudes of those who are asked to implement them, and their effectiveness. The literature shows that the implementation of such protocols has improved patient safety. In general, these efforts are viewed favorably by operating room personnel. However, the role of these checklists and other tools in reducing wrong-sided surgeries has not been proven. The goal of the health care profession should be to continue to improve on the advances that have been made in implementing surgical checklists and preventing wrong-site surgery. Practitioners at the authors' institution are continuously searching for ways to improve on the current protocols to prevent wrong-site surgeries. The authors recently employed a protocol in which surgical instruments are kept in the back of the room, away from the patient, until completion of the surgical time-out. This practice helps to ensure that team members are not distracted or preoccupied with setting up equipment during the time-out. This approach also helps to mitigate the hierarchal style in the operating room.

Electronically Mediated Time-out Initiative to Reduce the Incidence of Wrong Surgery

Background

“Wrong surgery” is defined as wrong site, wrong operation, or wrong patient, with estimated incidence up to 1 per 5,000 cases. Responding to national attention on wrong surgery, our objective was to create a care redesign intervention to minimize the rate of wrong surgery.

Methods

The authors created an electronic system using existing intraoperative electronic documentation to present a time-out checklist on large in-room displays. Time-out was dynamically interposed as a forced-function documentation step between “patient-in-operating room” and “incision.” Time to complete documentation was obtained from audit logs. The authors measured the postimplementation wrong surgery rate and used Bayesian methods to compare the pre- and postimplementation rates at our institution. Previous probabilities were selected using wrong surgery rate estimates from the observed performance reported in the literature to generate previous probabilities (4.24 wrong surgeries per 100,000 cases).

Results

No documentation times exceeded 5 min; 97% of documentation tasks were completed within 2 min. The authors performed 243,939 operations over 5 yr using the system, with zero wrong surgeries, compared with 253,838 operations over 6 yr with two wrong surgeries before implementation. Bayesian analysis suggests an 84% probability that the postimplementation wrong rate is lower than baseline. However, given the rarity of wrong surgery in our sample, there is substantial uncertainty. The total system-development cost was $34,000, roughly half the published cost of one weighted median settlement for wrong surgery.

Conclusion

Implementation of a forced-completion electronically mediated time-out process before incision is feasible, but it is unclear whether true performance improvements occur.

Wisdom in Medicine: What Helps Physicians After a Medical Error?

PURPOSE

Confronting medical error openly is critical to organizational learning, but less is known about what helps individual clinicians learn and adapt positively after making a harmful mistake. Understanding what factors help doctors gain wisdom can inform educational and peer support programs, and may facilitate the development of specific tools to assist doctors after harmful errors occur.

METHOD

Using "posttraumatic growth" as a model, the authors conducted semistructured interviews (2009-2011) with 61 physicians who had made a serious medical error. Interviews were recorded, professionally transcribed, and coded by two study team members (kappa 0.8) using principles of grounded theory and NVivo software. Coders also scored interviewees as wisdom exemplars or nonexemplars based on Ardelt's three-dimensional wisdom model.

RESULTS

Of the 61 physicians interviewed, 33 (54%) were male, and on average, eight years had elapsed since the error. Wisdom exemplars were more likely to report disclosing the error to the patient/family (69%) than nonexemplars (38%); P < .03. Fewer than 10% of all participants reported receiving disclosure training. Investigators identified eight themes reflecting what helped physician wisdom exemplars cope positively: talking about it, disclosure and apology, forgiveness, a moral context, dealing with imperfection, learning/becoming an expert, preventing recurrences/improving teamwork, and helping others/teaching.

CONCLUSIONS

The path forged by doctors who coped well with medical error highlights specific ways to help clinicians move through this difficult experience so that they avoid devastating professional outcomes and have the best chance of not just recovery but positive growth.

A National Survey to Evaluate Graduate Medical Education in Disparities and Limited English Proficiency: A Report From the AAIM Diversity and Inclusion Committee

OBJECTIVES

This article presents the results of a national survey addressing issues related to patients with limited English proficiency.

METHODS

We disseminated a national confidential survey to 391 program directors of Internal Medicine residency programs accredited by the Accreditation Council for Graduate Medical Education.

RESULTS

Seventy percent of program directors indicated that their residents cared for a patient population that was composed of more than 10% limited-English-proficiency patients. Nineteen percent of residency programs provided no education on caring for patients with limited English proficiency. Thirty percent of program directors felt that their faculty could not adequately evaluate residents on their ability to practice culturally competent care, and 68% cited lack of faculty expertise as a significant barrier to implementing a curriculum in cultural competency. Yet only 24% indicated that they had faculty development relevant to cultural competency and health care disparities.

CONCLUSIONS

Internal Medicine residents care for many patients with limited English proficiency. While it seems clear that an effective training curriculum is necessary, such a curriculum was not found to be uniformly present. Additionally, the lack of faculty expertise and faculty development in cultural competency and health care disparities is a significant barrier to the correction of this problem.

Health literacy in hand surgery patients: a cross-sectional survey

PURPOSE

To determine the prevalence of and factors associated with limited health literacy among outpatients presenting to an urban academic hospital-based hand surgeon.

METHODS

A cohort of 200 English- and Spanish-speaking patients completed the Newest Vital Sign (NVS) health literacy assessment tool, a sociodemographic survey, and 2 Patient-Reported Outcomes Measurement Information System-based computerized adaptive testing questionnaires: Patient-Reported Outcomes Measurement Information System Pain Interference and Upper-Extremity Function. The NVS scores were divided into limited (0-3) and adequate (4-6) health literacy. Multivariable regression modeling was used to identify independent predictors of limited health literacy.

RESULTS

A total of 86 patients (43%) had limited health literacy (English-speaking: 33%; Spanish-speaking: 100%). Factors associated with limited health literacy were advanced age, lower income, and being publicly insured or uninsured. Increasing years of education was a protective factor. Primary language was not included in the logistic regression model because all Spanish-speaking patients had limited health literacy. When evaluating health literacy on a continuum, primary language was the factor that most influenced the NVS scores, accounting for 14% of the variability.

CONCLUSIONS

Limited health literacy was commonplace among patients seeing a hand surgeon, more so in elderly and disadvantaged individuals. We hope our study raises awareness of this issue among hand surgeons and encourages providers to simplify messages and improve communication strategies.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Wrong site surgery in otolaryngology-head and neck surgery

OBJECTIVES/HYPOTHESIS

Wrong site surgery has received high public awareness this past decade, yet discussion specific to otolaryngology is limited.

STUDY DESIGN

Literature review.

METHODS

We searched the MEDLINE database on PubMed from 1980 to 2013 and pursued the citations of key references further. We conducted a review of the literature and public patient safety reports on the scope, root causes, and prevention of wrong site surgery with emphasis on otolaryngology.

RESULTS

A review of the literature reveals that otolaryngology procedures constitute 0.3% to 4.5% of all wrong site surgery events, and wrong site surgery accounts for 4% to 6% of all medical errors in otolaryngology. A significant proportion (9% to 21%) of otolaryngologists reported experiences with wrong site surgery over their career, and the events most frequently resulted in temporary injuries to the patient with few cases of permanent disability or death. Although otolaryngology procedures have similar root causes for wrong site events as other specialties, inverted imaging and ambiguity in site marking are particular challenges. Site-marking practices are variable among otolaryngologists, as it is not applicable to many otolaryngology procedures, yet these are common procedures that also constitute the majority of wrong site cases reported in otolaryngology.

CONCLUSIONS

Future interventions to address these challenges related to otolaryngology-head and neck surgery might involve a standardized protocol to confirm imaging accuracy, a specialty- or procedure-specific checklist, a standardized alternative to site marking when marking is impractical, and other innovations. Evaluation of these interventions is becoming easier given the increasing mandatory reporting of these events that provides more reliable incidence data.

How to Link outcomes data to quality initiatives in plastic surgery?

In recent decades, the expansion of health services research has created an opportunity to crate salient, evidence-based guidelines for diagnosis, treatment, and prognosis. However, for many aspects of care, incorporation of new scientific knowledge into clinical practice often lags, particularly among the surgical subspecialties. This article highlights the development of evidence-based medicine, the principles of innovation diffusion, and successes and challenges in developing plastic surgery quality initiatives.

Sharing Lessons Learned to Prevent Incorrect Surgery

The purpose of this report is to discuss surgical adverse event lessons learned and to recommend action. Examples of incorrect surgical adverse events managed in the Veterans Health Administration (VHA) patient safety system and results of a survey regarding the impact of the surgery lessons learned process are provided. The VHA implemented a process for sharing deidentified stories of surgical lessons learned. The cases are in-operating room selected examples from lessons learned from October 1, 2009, to June 30, 2011. Examples selected illustrate helpful human factors principles. To learn more about the awareness and impact of the lessons learned, we conducted a survey with Chiefs of Surgery in the VHA. The types of examples of adverse events include wrong eye implants, incorrect nerve blocks, and wrong site excisions of lesions. These are accompanied by human factors recommendations and change concepts such as designing the system to prevent mistakes, using differentiation, minimizing handoffs, and standardizing how information is communicated. The survey response rate was 76 per cent (88 of 132). Of those who had seen the surgical lessons learned (76% [67 of 88]), the majority (87%) reported they were valuable and 85% that they changed or reinforced patient safety behaviors in their facility as a result of surgical lessons learned. Simply having a policy will not ensure patient safety. When reviewing adverse events, human factors must be considered as a cause for error and for the failure to follow policy without assigning blame. VHA surgeons reported that the surgery lessons learned were valuable and impacted practice.

Wrong site surgery-where are we and what is the next step?

BACKGROUND

Wrong site surgery is estimated to occur 40 times per week in hospitals and clinics in USA. The universal protocol was implemented by the joint commission board of commissioners to address wrong site, wrong procedure, and wrong person surgery.

DISCUSSION

The universal protocol has three principal components: preoperative verification, marking of the operative site, and a time-out. Despite this organized approach to this problem, current data do not demonstrate any progress. In fact some data suggest that the problem may be getting worse. It is apparent that a process relying on surgeon and surgical team memory is doomed to ultimate failure. Recommendations are made for a more in depth checklist process based on the recommendations of the World Health Organization, reports in the literature of known areas of weakness in the current process, and personal experience in hopes of establishing a more bullet proof system to avoid wrong site procedure.

[Scaphoidectomy (instead of trapezectomy) in the treatment of rhizoarthrosis. Report of a case]

INTRODUCTION

Surgery site errors and technical errors in hand surgery are rare and not often published.

OBSERVATION

A 46-year-old patient with rhizoarthrosis of the left hand was initially treated by mistake in another center by a scaphoidectomy instead of a trapezectomy. She was seen in consultation 6months later, still suffering from her rhizoarthrosis and with carpal instability, clinically symptomatic and radiologically confirmed. The instability of the wrist was treated by a hamatocapito-lunar arthrodesis and a trapeziometacarpal arthrodesis was performed to treat the rhizoarthrosis. The clinical and radiological results were acceptable.

DISCUSSION

Besides the paradigmatic error, this observation confirms that the excision of the scaphoid quickly leads to a destabilization of the wrist, the capitatum no longer maintaining its alignment under the lunatum, and leads to a limitation of the wrist mobility and a loss of strength. The hamato-capito-lunate arthrodesis described in 1997 can treat wrist instability and only the trapeziometacarpal arthrodesis can, in the absence of scaphoid, treat the problem of rhizoarthrosis.

CONCLUSION

The authors recommend to always carry out a radiography of the wrist during trapezectomy surgery when there is doubt about the identification of the trapezium.

Challenges and barriers to improving care of the musculoskeletal patient of the future - a debate article and global perspective

Background

With greater technological developments in the care of musculoskeletal patients, we are entering an era of rapid change in our understanding of the pathophysiology of traumatic injury; assessment and treatment of polytrauma and related disorders; and treatment outcomes. In developed countries, it is very likely that we will have algorithms for the approach to many musculoskeletal disorders as we strive for the best approach with which to evaluate treatment success. This debate article is founded on predictions of future health care needs that are solely based on the subjective inputs and opinions of the world's leading orthopedic surgeons.

Hence, it functions more as a forum-based rather than a scientific-based presentation. This exposé was designed to stimulate debate about the emerging patients' needs in the future predicted by leading orthopedic surgeons that provide some hint as to the right direction for orthopedic care and outlines the important topics in this area.

Discussion

The authors aim to provide a general overview of orthopedic care in a typical developed country setting. However, the regional diversity of the United States and every other industrialized nation should be considered as a cofactor that may vary to some extent from our vision of improved orthopedic and trauma care of the musculoskeletal patient on an interregional level.

In this forum, we will define the current and future barriers in developed countries related to musculoskeletal trauma, total joint arthroplasty, patient safety and injuries related to military conflicts, all problems that will only increase as populations age, become more mobile, and deal with political crisis.

Summary

It is very likely that the future will bring a more biological approach to fracture care with less invasive surgical procedures, flexible implants, and more rapid rehabilitation methods. This international consortium challenges the trauma and implants community to develop outcome registries that are managed through health care offices and to prepare effectively for the many future challenges that lie in store for those who treat musculoskeletal conditions.