When experiencing repeated problems with surgical instruments that are broken, missing, or dirty, documentation of such problems is key to resolving the issue, says R. Stephen Trosty, JD, MHA, CPHRM, ARM, risk management and patient safety consultant in Haslett, MI.
Same-Day Surgery interviewed Trosty about the recent violations at Detroit Medical Center (DMC) involving surgical instruments handled by central sterile supply processing. Physicians complained for 11 years.
“Improper counts, instruments missing, delayed surgeries because of missing instruments, found contamination in instruments — that should have been documented,” Trosty says.
Facilities offering outpatient surgery should have structured mechanisms in place, in risk management and quality improvement (QI), to ensure these types of incidents are reported and investigated, he says. Regarding issues such as the ones with DMC instruments, “Every one of these should have resulted in an incident report, every one of which should be investigated by the risk manager, with a report going to his or her boss,” Trosty says.
The QI department should have conducted a sentinel event investigation into the individual complaints to determine if there was a pattern, Trosty says.
“If the pattern was ongoing, then the quality department should have been conducting a thorough evaluation of what was going on, and why it was going on, and what was being done to correct it.”
Every facility should have a quality committee with representatives including administrators, physicians, persons responsible for quality, and persons responsible for risk management, Trosty says. At DMC, “there should have been an investigation, and they should have been coming up with a whole slew of recommendations, and they should have been followed up on until there was adequate resolution,” he says.
Additionally, physicians’ complaints should have been going to the medical staff committee, through a surgery subcommittee, for investigation, Trosty says.
“All of this should have been going to the CEO and COO, as well as whoever oversaw quality and risk management,” he says.
Also, reports should have gone to members of the board, Trosty says, who “should have had the opportunity to hold the appropriate people accountable for correcting it.”
Reports also should have gone from nursing to the head of nursing, who should have looked into it, as well as persons overseeing the OR and sterilization functions, he says.
“Ultimately, if people did not know, they should have known,” Trosty says. “It’s astounding to me if they did not know, considering all the avenues that should have been in place.”