Digging deeper: How can you stop adverse events from happening?
Wrong patient/site/procedures, unintended retentions examined
The same adverse events seem to show up every year on national and state lists, and providers might be asking why, with all the emphasis on patient safety, these problems persist.
Part of the answer might be that providers are focused on the immediate, critical needs of the patient, such as the operation itself, says Teo Forcht Dagi, MD, DMedSc, FAANS, FACS, SAAANS, FCCM, chair of the American College of Surgeon’s Committee on Perioperative Care and a neurosurgeon. Dagi is a visiting professor at Harvard Medical School in Boston and professor at Queens University Belfast, Northern Ireland, UK.
“People were taught to do all kinds of things to prevent complications,” Forcht Dagi says. “As practical matter, we need a team to do that.” The team must not only take measures to care for the patient, but to protect the patient, he says.
Consider The Joint Commission’s no. 1 sentinel event for 2004-2012: “Wrong-patient, wrong-site, wrong-procedure.” There have been 928 cases reported since 2004, with 109 occurring in 2012 alone. In Minnesota, wrong-site surgeries/invasive procedures have been among the most commonly reported event in the nine years the state had been collecting data.
As surgery grows in complexity, these events continue to occur, says Rachel Blake Jokela, RRT, RCP, director of the Adverse Health Events Program in the Division of Health Policy, Minnesota Department of Health in St. Paul. “Fortunately we are catching these events earlier in the process,” Blake Jokela says. “For example, more often we are seeing wrong regional blocks prior to the actual surgical procedure, versus a wrong-sided knee arthroplasty for example.”
She says that when Minnesota Department of Health (MDH) officials looked at the root causes for wrong site/patient procedure in 2012, they found the following:
- laterality (left vs. right) or other critical information missing from informed consent documents;
- lack of site marking and/or lack of policy for correct site marking;
- lack of consistent and well-known time-out process;
- lack of verification of implant type prior to insertion.
“MDH and its partners will provide ongoing support to facilities to hardwire the time-out process, implement a standardized scheduling and verification process, and engage leaders to support their staff in speaking up for patient safety when concerns arise,” Blake Jokela says.
Teach staff to speak up
Speaking up is a key step, according to Forcht Dagi.
“People need to be able to express opinions or doubts,” he says. This starts with an introduction of everyone on the surgical team, Forcht Dagi says. “It is a lot easier to talk when you know what someone’s name is,” he says.
This communication allows everyone to agree on who the patient is and what the procedure is, so there are no surprises, Forcht Dagi says. “First and foremost, make sure communication among team is smooth, is open, and is adequate,” he says.
One of the root causes that shows up for wrong site/patient is barriers to communication, says Stephen Trosty, JD, MHA, CPHRM, ARM, president of Risk Management Consulting Corp. in Haslett, MI. These issues can include low English proficiency, literacy, and lack of ability to comprehend, which might be due to being upset over having surgery or being under the impact of anesthesia, Trosty says. “You may want to make sure you have patients repeat back to you to make sure they understand,” he says.
When an adverse event does occur, a root cause analysis is essential, Trosty says. Look at whether your processes allow the patient’s name and identifying number to be double-checked before they go in for surgery and once they are in the OR. Also, ensure your processes require having the actual site marked, then verified with the patient and medical record that the marked site is correct. The procedure also should be verified with the patient, physician, and medical record. “... [B]asically do a root cause analysis of what in the system may have gone wrong so you can, hopefully, prevent it from happening again,” Trosty says.
Also common: retention of a foreign body
The Joint Commission’s no. 3 sentinel event for 2004-2012 is “Unintended retention of a foreign body.” There have been 773 cases since 2004, with 115 reported in 2012.
In Minnesota, retained foreign objects declined by 16%, which was the first decline in this category in five years. “Many of the retained foreign objects for this past year were broken/fragments of items,” Blake Jokela says.
Forcht Dagi says that in terms of procedures to prevent retention of foreign objects, there have been procedures in place “for a hundred years.”
“The thing is, what we’ve done in the past seems very good, the surgery is essentially very safe, but it’s not good enough,” he says. “We may need to do things even better. “
Count and list all instruments and supplies ahead of time, Trosty says. “I even mean cotton swabs,” he says.
Check ahead of time to be sure everything on the list that is going in the patient is present on the tray, Forcht Dagi says. Technology can be as simple as a paper list of every instrument that is used and every device that might be put in. “As it’s removed, it’s checked against the list,” Forcht Dagi says.
There are technologies that allow labeling and automatic counting of instruments and devices, he says. Frequency-tracking devices can be useful. “What we ask is that the right combination of safety measures, safety education for the OR team, the right people are made accountable within the operating room, things are double checked, so that the retention of foreign bodies is prevented,” Forcht Dagi says.
After the procedure, count and list every object that is removed from the body and the tray, Trosty says. “There should be a double checking” by a separate staff member, he says.
If there is a discrepancy in the count, go in the patient and try to find the missing item, Trosty says.
Minnesota lists root causes of retentions
In Minnesota, root causes of retained items included the following:
- Staff didn’t realize that a device had broken. “This was often related to unfamiliarity with the device,” Blake Jokela says. “Either the team did not know what an intact device should look like, or they did not know that there was a risk for breakage with the particular device being used.”
- The retained device piece was so small that it wasn’t detected during inspections of the surgical field. “Over the years, this is most common with broken pieces of wire,” Blake Jokela says.
- The postoperative X-ray didn’t show the device fragment or piece due to its size.
Minnesota officials also commonly saw retention of “packed” items such as sponges during gynecological procedures. “These items are tucked by the surgical staff and intended to be removed prior to the end of the procedure,” Blake Jokela says. “The most common root cause for these types of events is an ineffective/ incomplete count process or lack of communication between staff regarding ‘tucked items.’”
If you have an unintended retention, review your processes and procedure, Trosty advises. Determine if the problem is with your system or with an individual who counted wrong, he says.
Communication is often a factor, Blake Jokely says. “As facilities continue to be challenged by packed items, it is clear that communication barriers can and do impact patient safety and lead to retained foreign objects,” she says. (To see an examination of falls as an adverse event, see story, below.)
The Agency for Healthcare Research and Quality has a new online toolkit, “Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care.” Web: www.ahrq.gov/research/ltc/fallpxtoolkit/index.html.
The Minnesota Hospital Association is conducting “SAFE SITE,” a statewide campaign to prevent wrong-site surgeries. To see information that hospitals and clinics are sharing, go to http://bit.ly/15v4ktJsee.
How can you prevent falls?
Falls in healthcare settings are “very common and sometimes difficult to prevent,” says Rachel Blake Jokela, RRT, RCP, director of the Adverse Health Events Program in the Division of Health Policy, Minnesota Department of Health in St. Paul.
In Minnesota in 2012, the type of event most likely to lead to serious patient harm or death was falls. Eighty cases of harm or death were a result of falls. And the problem is widespread. The Joint Commission’s no. 6 sentinel event for 2004-2012 is falls.
There are a million reasons patient can fall, says Teo Forcht Dagi, MD, DMedSc, FAANS, FACS, SAAANS, FCCM, chair of the American College of Surgeon’s Committee on Perioperative Care and a neurosurgeon. Dagi is a visiting professor at Harvard Medical School in Boston and professor at Queens University Belfast, Northern Ireland, UK. “They can be as prosaic as rails down on a bed, to the patient who seems fine but faints as soon as she gets out of bed, to someone under the effects of medication, especially in the outpatient surgery arena, who hasn’t quite recovered from anesthesia,” Forcht Dagi says.
Patients must be watched and monitored to make sure nothing untoward happens, he says. In outpatient surgery, patients must be carefully monitored because they sometimes walk into the OR, says Stephen Trosty, JD, MHA, CPHRM, ARM, president of Risk Management Consulting Corp., in Haslett, MI. “You want to make sure when they’re recovering ... someone is checking on them to make sure they don’t try to get off the table while still under the effects of sedation,” Trosty says. “From my experience, that’s when falls tend to occur: when you’re not paying enough attention to patient, not providing that assistance.”
And when falls occur, staff should protect patients against injuries, Blake Jokela says. Many falls can be attributed to breakdowns in the communications process in the fall risk assessment or the appropriateness of the interventions that are chosen, she says. “The fall risk was not adequately documented or communicated among team members or units,” Blake Jokela says. “The risk reduction interventions weren’t matched to the patient’s individual risk factors or weren’t consistently applied.”
This year, Minnesota facilities are focusing on linking risk assessment/injury assessment with individualized risk factors and proper interventions. “The hope is that this will help to decrease overall falls and significantly decrease fall-related injury,” Blake Jokela says.