1
|
Palm M, Braut GS. Obstacles to using the safe surgery checklist: Perspectives of first-line personnel. SAGE Open Med 2024; 12:20503121241278229. [PMID: 39315387 PMCID: PMC11418252 DOI: 10.1177/20503121241278229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 08/08/2024] [Indexed: 09/25/2024] Open
Abstract
Objectives The safe surgery checklist, presented by the World Health Organization in 2008, is an aid to performing surgical interventions safely. Research indicates that the use of checklists in clinical activities leads to a reduced number of adverse events. However, research suggests that the use of checklists differs between different institutions and even between units in the same organisation. The intention of this study is to identify factors regarded by the health personnel in 'the sharp end' as obstacles to using the checklist. Methods The study has a qualitative, case-based design. It is performed by the Hazard Identification method, which is a method for revealing safety hazards based on workers' experiences. Results Obstacles were identified related to the content of the list, areas of use, distribution of responsibilities connected with the use of the list, and finally the organisation and management of safety efforts related to clinical activities. The use of checklists must be part of a system's perspective, and deviations from checklists must be discussed in the organisation. The informants also claimed that checklists should be implemented for interventions located outside the operating theatres and for emergency treatments. Conclusions Even though the majority of employees believe that checklists are necessary, many surrounding factors are perceived as obstacles to their use. Not least, site-specific factors may be revealed by use of the Hazard Identification method.
Collapse
Affiliation(s)
| | - Geir Sverre Braut
- Stavanger University Hospital, Stavanger, Norway
- HVL Business School, Western Norway University of Applied Sciences, Bergen, Norway
| |
Collapse
|
2
|
Kapustin DA, Yun J, Su V, Rubin SJ, Modica I, Chung D, Fan J, Khan MN, Chai RL, Karasick M, Doyle S, Brandwein-Weber M, Urken ML. Frozen Section Timeout: Pilot Study to Reconcile Margins Using 3D Resected Specimen and Defect Scans. Laryngoscope 2024; 134:725-731. [PMID: 37466312 DOI: 10.1002/lary.30892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/28/2023] [Accepted: 07/02/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVE Opportunities exist to improve intraoperative communication and documentation of resection margin details. We instituted a "frozen section timeout" that centers around visualization of the paired resection specimen and surgical defect-facilitating effective, bidirectional exchange of information. METHODS We designed an interactive form for use during the "frozen section timeout" including annotated 3D virtual models of the resected specimen and surgical defect, plus a "line-item" table for primary and supplemental margin results. The "timeout" was conducted over a Zoom call between the operating room and frozen section laboratory. The form was simultaneously projected and discussed while all members of the surgical care team stopped activities. Nurses, co-surgeons, and all other members of the surgical team were encouraged to take part in this process. RESULTS Twenty-six frozen section timeouts were conducted during head and neck surgeries in the Department of Otolaryngology at Mount Sinai West Hospital. These timeouts were facilitated by the lead surgeon, and all other activities were halted to ensure that critical information was shared, documented, and agreed upon. During the timeout, the annotated specimen and defect scans were displayed, clearly demonstrating the at-risk margins and the corresponding location and breadth of supplemental margins harvested. CONCLUSION Incorporating a frozen section timeout can improve intraoperative communication, increase transparency, and potentially eliminate uncertainty regarding margin status and tumor clearance. Visualization of at-risk margins and the corresponding location and breadth of supplemental margins promises an unprecedented level of documentation and understanding. This novel technique can establish a new and improved standard of care. LEVEL OF EVIDENCE NA Laryngoscope, 134:725-731, 2024.
Collapse
Affiliation(s)
- Danielle A Kapustin
- THANC (Thyroid, Head & Neck Cancer) Foundation, New York, New York, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Jun Yun
- THANC (Thyroid, Head & Neck Cancer) Foundation, New York, New York, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Vivian Su
- THANC (Thyroid, Head & Neck Cancer) Foundation, New York, New York, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Samuel J Rubin
- THANC (Thyroid, Head & Neck Cancer) Foundation, New York, New York, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Ippolito Modica
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Daniel Chung
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Jun Fan
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Mohemmed N Khan
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Raymond L Chai
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Michael Karasick
- THANC (Thyroid, Head & Neck Cancer) Foundation, New York, New York, U.S.A
| | - Scott Doyle
- Department of Pathology and Anatomical Sciences, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, U.S.A
| | | | - Mark L Urken
- THANC (Thyroid, Head & Neck Cancer) Foundation, New York, New York, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| |
Collapse
|
3
|
Edge C, Widmeyer J, Hampton H, Satalich J, Hampton D, Vap A, Golladay G. Comparing surgeon perception to publicly reported data using NSQIP. J Orthop 2023; 42:34-39. [PMID: 37449024 PMCID: PMC10338147 DOI: 10.1016/j.jor.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023] Open
Abstract
Background Past studies have demonstrated that surgeons' perceptions of their own postsurgical complications may not be accurate. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database is a nationally validated, risk-adjusted, outcomes-based program created to measure and improve the quality of surgical care. Using information acquired through survey data, the purpose of this study is to determine how surgeons' perceptions of their own postoperative complications rates compare to the NSQIP database that tracks these outcome metrics. Hypothesis/purpose We hypothesize that surgeons underestimate their rates of morbidity, readmission, and reoperation within thirty days postoperatively when compared to NSQIP data. Study design Data elements such as perceived morbidity, readmission, and reoperation were collected through surveys distributed at a large level one trauma center. Survey respondents were asked how their rates compared to their peers and physician survey responses were then compared to institutional NSQIP data. Results 87.5% of surgeons underestimated their rates of morbidity, 35.4% underestimated their rates of readmission, 22.9% underestimated their rates of reoperation. When comparing themselves to their departmental averages, 57.78% accurately estimated their morbidity rates, 75.56% accurately estimated readmission rates, and 86.67% accurately estimated reoperation rates. Conclusion Surgeons are poor predictors of individual 30-day postoperative complication rates including morbidity, readmission, and reoperation. However, surgeons are more accurate in estimating these same outcomes when asked to compare to the average of their department.
Collapse
Affiliation(s)
- Carl Edge
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA, 23219, USA
| | - Jonathan Widmeyer
- Virginia Commonwealth University Medical School, Richmond, VA, 23219, USA
| | - Hailey Hampton
- Virginia Commonwealth University Medical School, Richmond, VA, 23219, USA
| | - James Satalich
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA, 23219, USA
| | - Dallas Hampton
- Eastern Virginia Medical School, Norfolk, VA, 23507, USA
| | - Alexander Vap
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA, 23219, USA
| | - Gregory Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA, 23219, USA
| |
Collapse
|
4
|
Rickert J. On Patient Safety: Quit Skipping Your Checklist-Based Time-Outs. Clin Orthop Relat Res 2023; 481:867-869. [PMID: 36999918 PMCID: PMC10097586 DOI: 10.1097/corr.0000000000002644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 03/07/2023] [Indexed: 04/01/2023]
Affiliation(s)
- James Rickert
- President, The Society for Patient Centered Orthopedics, Bloomington, IN, USA
| |
Collapse
|
5
|
Rohrmeier C, Abudan Al-Masry N, Keerl R, Bohr C, Mueller S. A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel. Eur Arch Otorhinolaryngol 2022; 279:5423-5431. [PMID: 35767060 PMCID: PMC9519680 DOI: 10.1007/s00405-022-07448-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/12/2022] [Indexed: 11/28/2022]
Abstract
Purpose Wrong-site surgeries are rare but potentially serious clinical errors. Marking the surgical site is crucial to preventing errors, but is hindered in the ENT field by the presence of many internal organs. In addition, there is no standardized marking procedure. Methods Here, an ENT surgical-marking procedure was developed and introduced at a clinic. The procedure was evaluated through anonymized questionnaires. This study was conducted over a 6-month period by interviewing patients and, at the beginning and end of this period, doctors and other surgical staff. Results The internal organ-marking problem was solved by applying a fixed abbreviation for each procedure onto the shoulder in addition to marking the skin surface as close to the organ as possible. The procedure was described as practicable by 100% of the interviewees; 75% of the ENT physicians and 96.3% of the other surgical staff considered the procedure highly important for preventing site confusion, and 75% of the physicians had a consequently greater feeling of safety. Of the 248 patients surveyed, 96.0% considered the marking procedure useful, and 75.8% had a consequently greater feeling of safety. For 52.0%, the marking reduced their fear of the operation. Conclusions For the first time, a standardized procedure was developed to mark the site of ENT surgery directly, uniformly and safely on patients. The procedure was judged to be useful and practicable and was also deemed crucial for preventing site confusion. Patients felt safer and less fearful of the operation due to the marking.
Collapse
Affiliation(s)
- Christian Rohrmeier
- Faculty of Medicine, University of Regensburg, 93042, Regensburg, Germany. .,ENT Medicinal Office, Bahnhofstr. 19, 94315, Straubing, Germany.
| | - Narmeen Abudan Al-Masry
- Department of Otorhinolaryngology, St. Elisabeth Hospital, St.-Elisabeth-Str. 23, 94315, Straubing, Germany
| | - Rainer Keerl
- Department of Otorhinolaryngology, St. Elisabeth Hospital, St.-Elisabeth-Str. 23, 94315, Straubing, Germany
| | - Christopher Bohr
- Department of Otorhinolaryngology, University of Regensburg, 93042, Regensburg, Germany
| | - Steffen Mueller
- Department of Oral and Maxillofacial Surgery, University of Regensburg, 93042, Regensburg, Germany
| |
Collapse
|
6
|
Patel SV, Olsen TW, Hinchley RL, Whipple DC, Kor TM. Improving Patient Safety in a High-Volume Intravitreal Injection Clinic. Ophthalmol Retina 2022; 6:495-500. [PMID: 35151914 DOI: 10.1016/j.oret.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/04/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine root causes of patient safety events in a high-volume intravitreal injection clinic, and to assess the effect of interventions to reduce the rate of events. DESIGN Quality improvement study. SUBJECTS All cases of intravitreal injection in a designated injection clinic between January 1, 2016 and December 31, 2019. METHODS The injection clinic model involved an injecting physician who usually differed from a prescribing physician. The procedural injection area was also physically separate from the retina outpatient clinic. Root cause analysis was used to determine factors that contributed to possible patient safety events in an institutional quality improvement project. Specific interventions were implemented to address each specific root cause. The rates of patient safety events (never events and near misses), whether associated with patient harm or not, were compared before and after intervention. MAIN OUTCOME MEASURES Frequency (%) of patient safety-related intravitreal injection events before (January 1, 2016 to December 31, 2018) and after (January 1, 2019 to December 31, 2019) intervention. RESULTS Root cause analysis included complex treatment plans that could be difficult to interpret, insufficient time to adequately review designated treatment plans, and risk of human error given the pace and volume of scheduled injections. Quality improvement strategies included revision of the standardized treatment plan documentation template, scheduling block-time for injecting physicians to review treatment plans within 24 hours of the injection clinic, and requiring agreement between dual, independent, site and medication verifications of the treatment plan by the injecting physician and an allied health coordinator prior to site marking. The rate of events before intervention was 0.1% (28/27400, or 9.3 events per year) and decreased to 0.01% (1/9375, or 1 event per year) after intervention (p=0.01). Most events were classified as near misses and there were no instances of patient harm. CONCLUSIONS A high level of patient safety can be achieved in a complex, high-volume intravitreal injection practice by recognizing potential safety issues and root causes, and implementing relevant quality improvements. While most events were near misses and no patients were harmed, reducing near misses can reduce the likelihood of harm associated with never events.
Collapse
Affiliation(s)
- Sanjay V Patel
- Department of Ophthalmology, Mayo Clinic, Rochester, MN.
| | | | | | - Daniel C Whipple
- Department of Management Engineering and Consulting, Mayo Clinic, Rochester, MN
| | - Todd M Kor
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
| |
Collapse
|
7
|
Liao X, Zhang P, Xu X, Zheng D, Wang J, Li Y, Xie L. Analysis of Factors Influencing Safety Attitudes of Operating Room Nurses and Their Cognition and Attitudes toward Adverse Event Reporting. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:8315511. [PMID: 35178235 PMCID: PMC8844141 DOI: 10.1155/2022/8315511] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/17/2022]
Abstract
Operating room nurses play a critical role in patient safety. The evaluation of safety attitudes of operating room nurses reflects their awareness and belief of patient safety. Currently, however, the research on the safety attitudes of operating room nurses is hard to track in the existing literature in China. Therefore, this paper was conducted to explore the factors influencing the safety attitudes of operating room nurses and their cognition and attitudes toward adverse event reporting. A total of 711 operating room nurses from 16 tertiary hospitals in Sichuan Province from March 1, 2018, to 2019 were selected. The general information of operating room nurses, such as age, gender, and years of service in the operating room, was obtained through the basic information questionnaire. The Chinese version of the Safety Attitudes Questionnaire (C-SAQ) was used to evaluate the safety attitude of operating room nurses, and the cognition and attitude of the subjects to adverse event reports were assessed through the questionnaire of cognition and attitude toward adverse event reporting. The average score of safety attitudes of operating room nurses was 4.20 ± 0.49. The two dimensions with a lower positive reaction rate of the safety attitudes of operating room nurses were stress recognition and working conditions. The main factors affecting the safety attitude of operating room nurses were night shifts, as well as cognition and attitudes toward adverse event reporting. There was a positive correlation between the total score of C-SAQ and the total score of cognition and attitudes toward adverse event reporting (P < 0.01, r = 0.445). The safety attitude of operating room nurses is at the upper-middle level, but the stress recognition and working conditions need to be improved. Through the allocation of nursing human resources, the strengthening of hospital logistics support, and the establishment of nonpunitive nursing adverse event reporting system, the operating room safety can be significantly enhanced.
Collapse
Affiliation(s)
- Xin Liao
- Department of Operating Room, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China
| | - Peijia Zhang
- Department of Operating Room, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China
| | - Xiaofeng Xu
- Department of Operating Room, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China
| | - Dan Zheng
- Department of Operating Room, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China
| | - Jing Wang
- Department of Operating Room, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China
| | - Yunfei Li
- Department of Operating Room, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China
| | - Li Xie
- Department of Operating Room, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China
| |
Collapse
|
8
|
Opportunities for nurse involvement in surgical antimicrobial stewardship strategies: a qualitative study. Int J Nurs Stud 2022; 128:104186. [DOI: 10.1016/j.ijnurstu.2022.104186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 01/18/2022] [Accepted: 01/20/2022] [Indexed: 10/19/2022]
|
9
|
Memon SI. A retrospective analysis of near-miss incidents at a tertiary care teaching hospital in Riyadh, KSA. J Taibah Univ Med Sci 2022; 17:235-240. [PMID: 35592803 PMCID: PMC9073884 DOI: 10.1016/j.jtumed.2021.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 11/09/2021] [Accepted: 11/29/2021] [Indexed: 12/02/2022] Open
Abstract
Objective This study seeks to establish an error-free reporting system that enhances patient safety and organisational culture. It investigates the prevalence of near-miss incident reporting systems by healthcare professionals in the General Surgery Department. Methods This retrospective observational study was conducted at a tertiary care teaching hospital in Riyadh, KSA. A sample of 253 medical records, ranging from January 2018 to December 2020, belonging to secondary patients was obtained using the near-miss Datix reporting and occurrence variance reporting system. The demographic variable data of registered patients were based on their age group (18–80 years), length of stay, date of admission, medication prescribed for more than four days, and whether they underwent surgical interventions. The cases were documented after the occurrence of a near-miss incident using a convenience sampling technique. Results In terms of prevalence in the near-miss main categories, medical errors were 248 (98.2%), workplace violations were two (0.80%), and others was one (0.40%). The number of incidence in the subcategories were: prescribing, 227 (89.7%); dispensing, 16 (6.30%) wrong dose/strength, 118 (46.6%), male, 123 (48.6%), and female, 130 (51.4%). The mean age and S.D. of patients was 1.94 ± 0.88 years and the demographic nationality as 1.16 ± 0.37. The one-sample t-test value for the main categories was −235 (p-value < 0.001). Conclusion Near-misses are recognised as essential targets for continuous quality improvement tools to mitigate preoperative incidents in hospitals. These findings can benefit the advancement of techniques for improving guidelines related to compliance and effective communication to improve the preoperative safety of patients.
Collapse
|
10
|
Critérios auditáveis para implementação de melhores práticas na adesão ao checklist cirúrgico. ACTA PAUL ENFERM 2021. [DOI: 10.37689/acta-ape/2021ao00515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
11
|
Venkatesh R, Tagare S, Kaur K, Gurnani B, Nair M, Prasad S. Presbyopic glide: A simple aid to prevent grave errors in high surgical volume centers. Indian J Ophthalmol 2021; 69:1345-1346. [PMID: 33913905 PMCID: PMC8186593 DOI: 10.4103/ijo.ijo_3352_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Rengaraj Venkatesh
- Chief Medical Officer, Consultant Glaucoma Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, India
| | - Shivraj Tagare
- Primary DNB Resident, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, India
| | - Kirandeep Kaur
- Consultant Pediatric Ophthalmology and Strabismus Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, India
| | - Bharat Gurnani
- Consultant Cornea and Refractive Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, India
| | - Megha Nair
- Primary DNB Resident, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, India
| | - Sushad Prasad
- Primary DNB Resident, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, India
| |
Collapse
|
12
|
Abstract
The incidence of surgical complications has remained largely unchanged over the past two decades. Inherent complexity in surgery, new technology possibilities, increasing age and comorbidity in patients may contribute to this. Surgical safety checklists may be used as some of the tools to prevent such complications. Use of checklists may reduce critical workload by eliminating issues that are already controlled for. The global introduction of the World Health Organization Surgical Safety Checklist aimed to improve safety in both anesthesia and surgery and to reduce complications and mortality by better teamwork, communication, and consistency of care. This review describes a literature synthesis on advantages and disadvantages in use of surgical safety checklists emphasizing checklist development, implementation, and possible clinical effects and using a theoretical framework for quality of provided healthcare (structure-process-outcome) to understand the checklists' possible impact on patient safety.
Collapse
|
13
|
Using a Second Stakeholder-Driven Variance Reporting System Improves Pediatric Perioperative Safety. Pediatr Qual Saf 2019; 4:e220. [PMID: 31745523 PMCID: PMC6831050 DOI: 10.1097/pq9.0000000000000220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 08/28/2019] [Indexed: 11/26/2022] Open
Abstract
Despite recognizing the occurrence of variances, we noted a low rate of reporting with the established computer variance program. Therefore, we developed and introduced a simple, handwritten variance reporting system. The goal of this study was to compare our pediatric perioperative handwritten variance cards to our established computerized variance reporting system. Methods We developed a handwritten variance card program through a stakeholder-driven quality-improvement initiative. We collected variances from handwritten cards in 4 perioperative locations and also from the established computerized variance system. We analyzed the variances and categorized them into 6 safety domains and 5 variance categories. Results Over 6 consecutive years, 3,434 variances were reported (687 computerized and 2,747 handwritten). For safety domains, the computerized system was more likely to capture adverse events and near-misses (8.7% vs. 1.1%, P < 0.001; 23.5% vs. 8.6%, P < 0.001, respectively) while the handwritten system was more likely to identify the safety process and other non-safety issues (20.1% vs. 38.3%, P < 0.001). Both systems addressed policy/process issues most often, with 37.9% of the handwritten cards and 66.6% of the computerized variance reports. Of the handwritten cards with a patient identifier (n = 1,407), only 5.1% (n = 72) also had a computerized variance filed about the same event. Thus, staff reported >1,300 additional variances that were not identified with the computerized variance system alone. Conclusion The handwritten, stakeholder-driven variance reporting system was essential to identify local and system issues that would not have been identified by the computerized variance reporting system alone.
Collapse
|
14
|
Papadakis M, Meiwandi A, Grzybowski A. The WHO safer surgery checklist time out procedure revisited: Strategies to optimise compliance and safety. Int J Surg 2019; 69:19-22. [PMID: 31310820 DOI: 10.1016/j.ijsu.2019.07.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/01/2019] [Accepted: 07/06/2019] [Indexed: 10/26/2022]
|
15
|
Differing perceptions of preoperative communication among surgical team members. Am J Surg 2019; 217:1-6. [DOI: 10.1016/j.amjsurg.2018.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 05/25/2018] [Accepted: 06/01/2018] [Indexed: 11/19/2022]
|
16
|
Safety culture among pediatric surgeons: A national survey of attitudes and perceptions of patient safety. J Pediatr Surg 2018; 53:381-395. [PMID: 29111082 DOI: 10.1016/j.jpedsurg.2017.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/22/2017] [Accepted: 09/26/2017] [Indexed: 01/14/2023]
Abstract
PURPOSE Improving the culture of safety within health care is an essential component of preventing errors and improving overall health care quality. The purpose of this study was to characterize the attitudes and perceptions of patient safety among pediatric surgeons. METHODS We conducted a cross-sectional online survey of American Pediatric Surgery Association members. Survey items assessed surgeons' knowledge, attitudes, and perceptions of patient safety. We performed descriptive statistics and evaluated associations between respondent characteristics and survey responses. RESULTS Response rate was 38% (353/928). Surgeons in academic practice (96% vs 83% private, P=0.01) and in leadership positions (98% vs 92%, P=0.03) were more likely to feel actively engaged in patient safety initiatives. Surgeons in private practice were less likely to feel safe having their own children undergo surgery at their institution (80% vs 96% academic, P<0.005). CONCLUSION Pediatric surgeons have disparate attitudes and perceptions of patient safety within their hospitals. Significant variation exists based on surgeon characteristics. These findings underscore the need to identify barriers to surgeon engagement and develop educational initiatives to empower surgeons as leaders in improving patient safety culture. LEVEL OF EVIDENCE V.
Collapse
|
17
|
Anderson KT, Bartz-Kurycki MA, Masada KM, Abraham JE, Wang J, Kawaguchi AL, Austin MT, Kao LS, Lally KP, Tsao K. Decreasing intraoperative delays with meaningful use of the surgical safety checklist. Surgery 2018; 163:259-263. [DOI: 10.1016/j.surg.2017.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 06/23/2017] [Accepted: 08/01/2017] [Indexed: 11/17/2022]
|
18
|
Hamilton EC, Pham DH, Minzenmayer AN, Austin MT, Lally KP, Tsao K, Kawaguchi AL. Are we missing the near misses in the OR?-underreporting of safety incidents in pediatric surgery. J Surg Res 2017; 221:336-342. [PMID: 29229148 DOI: 10.1016/j.jss.2017.08.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/28/2017] [Accepted: 08/01/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Electronic hospital variance reporting systems used to report near misses and adverse events are plagued by underreporting. The purpose of this study is to prospectively evaluate directly observed variances that occur in our pediatric operating room and to correlate these with the two established variance reporting systems in our hospital. MATERIALS AND METHODS Trained individuals directly observed pediatric perioperative patient care for 6 wk to identify near misses and adverse events. These direct observations were compared to the established handwritten perioperative variance cards and the electronic hospital variance reporting system. All observations were analyzed and categorized into an additional six safety domains and five variance categories. The chi-square test was used, and P-values < 0.05 were considered statistically significant. RESULTS Out of 830 surgical cases, 211 were audited by the safety observers. During this period, 137 (64%) near misses were identified by direct observation, while 57 (7%) handwritten and 8 (1%) electronic variance were reported. Only 1 of 137 observed events was reported in the handwritten variance system. Five directly observed adverse events were not reported in either of the two variance reporting systems. Safety observers were more likely to recognize time-out and equipment variances (P < 0.001). Both variance reporting systems and direct observation identified numerous policy and process issues. CONCLUSIONS Despite multiple reporting systems, near misses and adverse events remain underreported. Identifying near misses may help address system and process issues before an adverse event occurs. Efforts need to be made to lessen barriers to reporting in order to improve patient safety.
Collapse
Affiliation(s)
- Emma C Hamilton
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Dean H Pham
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Andrew N Minzenmayer
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Mary T Austin
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
| | - Akemi L Kawaguchi
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
| |
Collapse
|
19
|
Nelson PE. Enhanced Time Out: An Improved Communication Process. AORN J 2017; 105:564-570. [DOI: 10.1016/j.aorn.2017.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/23/2016] [Accepted: 03/29/2017] [Indexed: 10/19/2022]
|
20
|
Moe JS, Abramowicz S, Roser SM. Quality Improvement and Reporting Systems: What the Oral and Maxillofacial Surgeon Should Know. Oral Maxillofac Surg Clin North Am 2017; 29:229-238. [PMID: 28417894 DOI: 10.1016/j.coms.2016.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Health care is an inherently dangerous environment, and patient safety should be an explicit goal of oral and maxillofacial surgery. Important components of a safety program include a nonpunitive safety culture, the implementation of patient safety practices, standardized incident reporting and adverse event analysis, regular self-assessment, and internal and external benchmarking. Implementation of a safety program requires the strong commitment of leadership and the engagement and empowerment of all employees. Oral and maxillofacial surgery can become the model dental specialty by implementing patient safety programs for office-based surgery. The programs could then be used by all dental practitioners performing oral surgery in the office.
Collapse
Affiliation(s)
- Justine S Moe
- Division of Oral and Maxillofacial Surgery, Department of Surgery, Emory University School of Medicine, 1365B Clifton Road, Atlanta, GA 30322, USA
| | - Shelly Abramowicz
- Division of Oral and Maxillofacial Surgery, Department of Surgery, Emory University School of Medicine, 1365B Clifton Road, Atlanta, GA 30322, USA
| | - Steven M Roser
- Division of Oral and Maxillofacial Surgery, Department of Surgery, Emory University School of Medicine, 1365B Clifton Road, Atlanta, GA 30322, USA.
| |
Collapse
|
21
|
Weingessel B, Haas M, Vécsei C, Vécsei-Marlovits PV. Clinical risk management - a 3-year experience of team timeout in 18 081 ophthalmic patients. Acta Ophthalmol 2017; 95:e89-e94. [PMID: 27422210 DOI: 10.1111/aos.13155] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 05/12/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE Clinical risk management aims to identify, analyse and avoid errors and risks systematically to improve patient's safety. Preoperative checklists to prevent mistakes have gained importance in the last few years. A so-called team timeout checklist was introduced in October 2011 at the Department of Ophthalmology, Hietzing Hospital, Vienna. The purpose of the study is to evaluate the benefits and demonstrate the value of team timeout. METHODS After the team timeout had been in use for 6 months, all near misses that occurred over a period of 34 months were assigned to the following groups: wrong side, wrong lens, wrong patient and miscellaneous. RESULTS Eighteen thousand and eighty-one surgeries were performed in the specified period; 53 cases of 'wrong side' and 52 cases of 'wrong intraocular lens' were noted. Ninety-six near misses concerned the patients' data and 38 concerned documentation. A reduction of near misses was noted after an adaptation phase of 3 months. CONCLUSIONS Team timeout proved valuable, as it improved the patients' safety with minimum effort. Errors may occur despite several preoperative controls and can be detected by performing team timeout.
Collapse
Affiliation(s)
- Birgit Weingessel
- Department of Ophthalmology; Hietzing Hospital; Vienna Austria
- Karl Landsteiner Institute for Process Optimization and Quality Management in Cataract Surgery; Vienna Austria
| | - Michaela Haas
- Department of Ophthalmology; Hietzing Hospital; Vienna Austria
| | - Christina Vécsei
- Karl Landsteiner Institute for Process Optimization and Quality Management in Cataract Surgery; Vienna Austria
| | - Pia Veronika Vécsei-Marlovits
- Department of Ophthalmology; Hietzing Hospital; Vienna Austria
- Karl Landsteiner Institute for Process Optimization and Quality Management in Cataract Surgery; Vienna Austria
| |
Collapse
|
22
|
Kozusko SD, Elkwood L, Gaynor D, Chagares SA. An Innovative Approach to the Surgical Time Out: A Patient-Focused Model. AORN J 2016; 103:617-22. [DOI: 10.1016/j.aorn.2016.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 11/06/2015] [Accepted: 04/06/2016] [Indexed: 10/21/2022]
|
23
|
Santana HT, Rodrigues MCS, do Socorro Nantua Evangelista M. Surgical teams' attitudes and opinions towards the safety of surgical procedures in public hospitals in the Brazilian Federal District. BMC Res Notes 2016; 9:276. [PMID: 27188751 PMCID: PMC4869202 DOI: 10.1186/s13104-016-2078-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 05/06/2016] [Indexed: 01/01/2023] Open
Abstract
Background According to the World Health Organization, the WHO surgical safety checklist can prevent complications, improve communication and contribute to postsurgical safety culture; hence, there is a need to investigate the attitudes and opinions of surgical teams regarding safety utilizing the WHO instrument. The aim of this study was to assess the attitudes and opinions towards surgical safety among operating room professionals in three public hospitals in the Brazilian Federal District. Methods A cross-sectional study was conducted with the use of a checklist based on the safety attitudes questionnaire-operating room, sent out during the pre- and post-intervention surveys of the WHO surgical safety checklist (period I and period II) between 2012 and 2014. Results About 470 professionals, mostly nurse technicians, responded to the questionnaire in both periods. Regarding the perception of safety and agreement about the collaboration of the operating team, a significant statistical improvement of the nursing staff and anesthesiologists was observed in the operating room after the checklist was implemented. After utilizing the checklist before each surgical procedure, concerns about patient safety and compliance with standards as well as rules and hand-washing practices in the operating room statistically improved after the post-intervention, especially by the nursing staff. The checklist was considered easy and quick to use by most respondents. They also believed that the checklist inclusion improved communication, reflecting significant differences. At least 90.0 % of respondents from each team agreed that the checklist helps prevent errors in the operating room. Conclusions The study results showed progress in relation to the attitudes and opinions regarding surgical safety from operating teams in relation to the checklist response in the surveyed units. However, difficulties in its implementation are experienced, especially in relation to checklist use acceptance by the surgeons. New studies are needed to verify the sustainability of the surgical teams’ changes in attitudes in the hospitals studied.
Collapse
Affiliation(s)
- Heiko Thereza Santana
- National Health Surveillance Agency, SIA trecho 5, área especial 57, Brasilia, DF, 71205-050, Brazil.
| | - Maria Cristina Soares Rodrigues
- Department of Nursing, Faculty of Health Sciences of the University of Brasilia (UnB), Campus Darcy Ribeiro, Brasilia, DF, 70910-900, Brazil
| | | |
Collapse
|
24
|
Abstract
This systematic review aimed to assess surgical safety checklist compliance and evaluate surgical team perceptions and attitudes, post-checklist implementation in the operating room. The World Health Organization (WHO) surgical safety checklist (SSC) has decreased complications and mortality. However, it is unclear whether this reduction is influenced by the vicarious enhancement in teamwork, communication, and staff awareness established by SSC implementation. The preferred reporting items for systematic reviews and meta-analyses model of review guided a search across MEDLINE, PubMed, and Embase databases. English-language studies using any adapted form of the WHO-SSC in operating rooms were reviewed by abstract and full text. Twenty-six studies, 13 assessing SSC compliance and 13 investigating surgical team perceptions of SSC, were evaluated. Compliance studies showed a checklist initiation rate of >90%, but actual observed completion rate varied widely across studies. Sign out was the most poorly performed phase of the checklist (<50%) with time out being the best. Verification of patient identity and procedure demonstrated a high degree (>90%) of compliance across studies, but “verification of team-members” was significantly less compliant. Studies assessing surgical team perceptions found that SSC improved participants' perception of teamwork, communication, patient safety, and staff awareness of adverse events. However, when stakeholders placed differing degrees of importance on SSC completion, results indicated the SSC might actually antagonize team relationships. SSC compliance varies significantly across studies, being highly dependent on staff perceptions, training, and effective leadership. Surgical teams have positive perceptions of SSC; thus with effective implementation strategies, compliance rates across all phases can be substantially improved.
Collapse
|
25
|
Healey T, El-Othmani MM, Healey J, Peterson TC, Saleh KJ. Improving Operating Room Efficiency, Part 1: General Managerial and Preoperative Strategies. JBJS Rev 2015; 3:01874474-201510000-00003. [PMID: 27490788 DOI: 10.2106/jbjs.rvw.n.00109] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Travis Healey
- Southern Illinois University School of Medicine, P.O. Box 19679, Springfield, IL 62794-9679
| | - Mouhanad M El-Othmani
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, P.O. Box 19679, Springfield, IL 62794-9679
| | - Jessica Healey
- Southern Illinois University School of Medicine, P.O. Box 19679, Springfield, IL 62794-9679
| | - Todd C Peterson
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, P.O. Box 19679, Springfield, IL 62794-9679
| | - Khaled J Saleh
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, P.O. Box 19679, Springfield, IL 62794-9679
| |
Collapse
|
26
|
Epstein NE. Multidisciplinary in-hospital teams improve patient outcomes: A review. Surg Neurol Int 2014; 5:S295-303. [PMID: 25289149 PMCID: PMC4173201 DOI: 10.4103/2152-7806.139612] [Citation(s) in RCA: 202] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 06/12/2014] [Indexed: 01/08/2023] Open
Abstract
Background: The use of multidisciplinary in-hospital teams limits adverse events (AE), improves outcomes, and adds to patient and employee satisfaction. Methods: Acting like “well-oiled machines,” multidisciplinary in-hospital teams include “staff” from different levels of the treatment pyramid (e.g. staff including nurses’ aids, surgical technicians, nurses, anesthesiologists, attending physicians, and others). Their enhanced teamwork counters the “silo effect” by enhancing communication between the different levels of healthcare workers and thus reduces AE (e.g. morbidity/mortality) while improving patient and healthcare worker satisfaction. Results: Multiple articles across diverse disciplines incorporate a variety of concepts of “teamwork” for staff covering emergency rooms (ERs), hospital wards, intensive care units (ICUs), and most critically, operating rooms (ORs). Cohesive teamwork improved communication between different levels of healthcare workers, and limited adverse events, improved outcomes, decreased the length of stay (LOS), and yielded greater patient “staff” satisfaction. Conclusion: Within hospitals, delivering the best medical/surgical care is a “team sport.” The goals include: Maximizing patient safety (e.g. limiting AE) and satisfaction, decreasing the LOS, and increasing the quality of outcomes. Added benefits include optimizing healthcare workers’ performance, reducing hospital costs/complications, and increasing job satisfaction. This review should remind hospital administrators of the critical need to keep multidisciplinary teams together, so that they can continue to operate their “well-oiled machines” enhancing the quality/safety of patient care, while enabling “staff” to optimize their performance and enhance their job satisfaction.
Collapse
Affiliation(s)
- Nancy E Epstein
- Winthrop University Hospital, Chief of Neurosurgical Spine, Education, and Research, Mineola, NY 11501, USA
| |
Collapse
|
27
|
Herasevich V, Ellsworth MA, Hebl JR, Brown MJ, Pickering BW. Information needs for the OR and PACU electronic medical record. Appl Clin Inform 2014; 5:630-41. [PMID: 25298804 DOI: 10.4338/aci-2014-02-ra-0015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 06/01/2014] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The amount of clinical information that anesthesia providers encounter creates an environment for information overload and medical error. In an effort to create more efficient OR and PACU EMR viewer platforms, we aimed to better understand the intraoperative and post-anesthesia clinical information needs among anesthesia providers. MATERIALS AND METHODS A web-based survey to evaluate 75 clinical data items was created and distributed to all anesthesia providers at our institution. Participants were asked to rate the importance of each data item in helping them make routine clinical decisions in the OR and PACU settings. RESULTS There were 107 survey responses with distribution throughout all clinical roles. 84% of the data items fell within the top 2 proportional quarters in the OR setting compared to only 65% in the PACU. Thirty of the 75 items (40%) received an absolutely necessary rating by more than half of the respondents for the OR setting as opposed to only 19 of the 75 items (25%) in the PACU. Only 1 item was rated by more than 20% of respondents as not needed in the OR compared to 20 data items (27%) in the PACU. CONCLUSION Anesthesia providers demonstrate a larger need for EMR data to help guide clinical decision making in the OR as compared to the PACU. When creating EMR platforms for these settings it is important to understand and include data items providers deem the most clinically useful. Minimizing the less relevant data items helps prevent information overload and reduces the risk for medical error.
Collapse
Affiliation(s)
- V Herasevich
- Department of Anesthesiology, Mayo Clinic College of Medicine , Rochester, MN ; Multidisciplinary Epidemiology and Translation Research in Intensive Care (METRIC), Mayo Clinic College of Medicine , Rochester, MN
| | - M A Ellsworth
- Division of Neonatal Medicine, Mayo Clinic College of Medicine , Rochester, MN
| | - J R Hebl
- Department of Anesthesiology, Mayo Clinic College of Medicine , Rochester, MN
| | - M J Brown
- Department of Anesthesiology, Mayo Clinic College of Medicine , Rochester, MN
| | - B W Pickering
- Department of Anesthesiology, Mayo Clinic College of Medicine , Rochester, MN ; Multidisciplinary Epidemiology and Translation Research in Intensive Care (METRIC), Mayo Clinic College of Medicine , Rochester, MN
| |
Collapse
|
28
|
Abstract
Objective Because wrong-site confusion is among the most common mistakes in the operations of paired organs, we have examined the frequency of wrong-sided confusions that could theoretically occur in cataract surgeries in the absence of preoperative verification. Methods Ten cataract surgeons participated in the study. The surgeons were asked to complete a questionnaire that included their demographic data, occupational habits, and their approach to and the handling of patients preoperatively. On the day of operation, the surgeons were asked to recognize the side of the operation from the patient’s name only. At the second stage of the study, surgeons were asked to recognize the side of the operation while standing a 2-meter distance from the patient’s face. The surgeons’ answers were compared to the actual operation side. Patients then underwent a full time-out procedure, which included side marking before the operation. Results Of the total 67 patients, the surgeons correctly identified the operated side of the eye in 49 (73%) by name and in 56 (83%) by looking at patients’ faces. Wrong-side identification correlated with the time lapsed from the last preoperative examination (P=0.034). The number of cataract surgeries performed by the same surgeon (on the same day) also correlated to the number of wrong identifications (P=0.000). Surgeon seniority or age did not correlate to the number of wrong identifications. Conclusion This study illustrates the high error rate that can result in the absence of side marking prior to cataract surgery, as well as in operations on other paired organs.
Collapse
Affiliation(s)
- Dvora Pikkel
- Risk Management and Patient Safety Unit, Assuta Hospital, Ramat Hachayal, Tel-Aviv, Israel
| | - Adi Sharabi-Nov
- Research Wing, Ziv Medical Center, Safed, Israel ; Tel-Hai Academic College, Upper Galilee, Israel
| | - Joseph Pikkel
- Department of Ophthalmology, Ziv Medical Center, Safed, Israel ; Faculty of Medicine, Bar-Ilan University, Ramat Gan, Tel Aviv, Israel
| |
Collapse
|