Facility revamps safety after wrong-site surgery

(Editor's note: This issue includes the first part of a two-part series on how a hospital addressed a wrong-site surgery. This month, we look at the details of the event and how the facility responded. Next month we look at what specific changes were made and how the top leader started networking with other CEOs on safety issues.)

When a surgeon at Cayuga Medical Center in Ithaca, NY, performed a procedure on the wrong side of a patient's back in 2008, the sentinel event stunned the hospital's administration. But it wasn't long before hospital leaders were formulating a plan to make sure it never happened again.

The result has been a series of improvements that make the hospital a leader in patient safety.

The wrong-site error occurred in June 2008, says Cayuga CEO Rob Mackenzie, MD. The state health department investigated and issued an order in October 2008 that stipulated a fine of $8,000, along with requiring a plan of correction, continuing reviews of documentation of the surgical protocol checklist, three observations of pre-surgery procedures every day at the main campus and two a day at the hospital's outpatient surgery center, and quarterly progress reports to be submitted to the health department, according to information provided by the health department. Cayuga submitted its plan of correction by the end of 2008 and implemented it over the next two years.

The wrong-site surgery occurred because a staff member and the surgeon didn't follow the hospital's safety protocol, says David Evelyn, MD, vice president for medical affairs at Cayuga. Before the surgery intended to relieve the female patient's back pain, the surgeon and patient had agreed the operation would address only the left side, the source of the worst pain. But when the surgeon made a midline incision and found diseased tissue on both sides of the patient's back, he erroneously operated on the right side, Evelyn says

When that procedure was complete, the surgeon realized his error and operated on the left side, Evelyn says. The surgeon informed the patient and her family of the error immediately, and the hospital informed the state health department, Mackenzie says. The woman's back pain was relieved, and she did not sue the hospital.

The error happened because two steps of the hospital's safety protocols were not followed, Evelyn says. First, the scheduler did not specify on the schedule the exact location of the surgery, and the surgeon did not mark the surgical site beforehand.

Though the wrong-site surgery resulted in no grievous harm to the patient, Mackenzie says he and his colleagues considered it a serious warning sign that patient safety was not receiving proper attention at the hospital. He called together the medical executive committee and board of directors, and he asked them to form a task force on hospital safety. "That task force worked quickly over the next six weeks to hear from all parts of our organization, not just surgery, but also environmental services, pharmacy, patient units, and we learned that we had not raised safety to the level we needed to," Mackenzie says. "We needed to say that safety at Cayuga Medical Center is the foundation for our clinical care and really needs to be job one."

Studied high reliability

The task force studied high reliability organizations such as the National Aeronautics and Space Administration (NASA) and the aviation industry to look for characteristics that were common and to determine how Cayuga could develop them within its organization, Evelyn says. One of the first conclusions was that organizations known for safety had a culture different from the typical hospital, and it was one in which safety was always at the forefront of everyone's mind.

Secondly, these organizations all had a specific safety leader to whom everyone looked for guidance and support. Also, they all had organizational structures uncommon in hospitals, in which safety was emphasized and monitored at the lowest levels rather than being mandated from the top. But at the same time, they had an executive-level emphasis on safety that supported the culture of safety.

The high reliability organizations also had boards that were actively involved in promoting a culture of safety, Evelyn says. "Clearly there were common themes among these high reliability organizations, and we needed to adopt these at Cayuga," he says. "We wanted to be a high reliability hospital and we set out to achieve that."

Incident reporting simplified

The hospital implemented a just culture approach to encourage reporting of incidents and near misses, and part of that change was making the reporting procedure much simpler. Rather than using a multi-page written form, Cayuga staff now can report concerns on a one-page online form, Mackenzie says. As a result, the number of reported incidents went up sharply, Evelyn says.

Those reports are used to deploy resources and tailor training efforts to the hospital's particular needs, he says. Staff satisfaction surveys also are showing significant improvement on questions related to whether employees feel their superiors listen to their concerns and how they rate the hospital as a good place to work.

Since implementing the changes, there has been no new wrong-site error or other sentinel event, Evelyn says. The hospital has achieved 100% compliance with the Universal Protocol. During a recent survey by The Joint Commission, the surveyors complimented the hospital on how every physician knew the Universal Protocol procedure by heart.

"They said they've never seen that before. In other organizations, it's always led by the nurses, or there is a script on the wall," Evelyn says. "We've seen a dramatic change in the way people think about things. It's not just about how to get through your work day anymore; it's about how to get your patient through the day as safely as possible."