Wrong Site Surgery: Learning from MN s adverse events reporting system

1. Wrong Site Surgery: Learning from MN�s adverse events reporting system Diane Rydrych Division of Health Policy MN Department of Health

2. Overview How common are wrong-site procedures in MN, and what do they look like? What does national data show? Why does it happen? How well do MN facilities follow the safe-site protocol?

3. WSS in Minnesota

4. WSS in Minnesota

5. Types of Procedures

6. Where does WSS happen?

7. Where does WSS happen?

8. Patient Outcomes

9. Non-OR procedures

10. VA National Center for Patient Safety 1/30,000 surgeries, 1 WSS/month (2001) 44% left/right mix-ups 36% wrong patient 14% wrong implant or procedure 7% wrong site (not left/right) MN Rate: ? No good data on # of invasive procedures

11. VA National Center for Patient Safety Eye Groin or Genitals Chest Leg Hand, Wrist, or Finger Abdomen Back Head, Neck, Mouth, Anus, Colon, Buttock

12. Joint Commission

13. Pennsylvania�s experience 174 WSS cases and 239 near misses in 30 months

14. Pennsylvania�s experience Which factors contributed most strongly to prevention? Surgeon being involved in pre-op verification and reconciliation, including verification with office records, consent, and medical records Having correct and complete information for pre-op verification Participation by anesthesia in time-out before patient is touched Correct site marking and patient positioning/prep

15. Pennsylvania�s experience Recommendations: Full surgeon involvement in verification and time-out, possibly through pre-op briefing Include site/side on consent form and in notes Include all relevant documentation in verification Mini-time out with any repositioning Have reliable system for transmitting info from surgeon�s office to OR nurse/team Team training for OR Surgeon discusses any changes in plan or new information with team

16. Preventing WSS But�..we have a protocol to prevent WSS, right? We do. But do we use it?

17. Preventing WSS Registry modified to include questions related to protocol: Did OR schedule and consent match? Did the surgeon sign the site in pre-op? Did he/she sign with initials? Was there active, verbal participation in a time-out? Was there a second pause for internal laterality? For spinal procedures, pre-op and intra-op x-rays?

18. Preventing WSS OR schedule/consent matched: 15.5% No Surgeon signed site with initials 50.0% No Verbal participation in time-out 46.5% No Every step followed 15.5% There were a few cases that came close to having every step, but there was always a crucial piece that was missed � no intraoperative xray for spinal cases, site marked but mark not visualized before incision, lens power not verified as part of pause, no policy for time out for anesthesia/ regional blocks (so actual surgery was correct, but not the block), etc.There were a few cases that came close to having every step, but there was always a crucial piece that was missed � no intraoperative xray for spinal cases, site marked but mark not visualized before incision, lens power not verified as part of pause, no policy for time out for anesthesia/ regional blocks (so actual surgery was correct, but not the block), etc.

19. Preventing WSS What went wrong? Incomplete/unclear policies No policy in some parts of facility Chaos/confusion/distraction Cultural issues Visibility of site marking Lack of team involvement Time pressures/staffing Communication breakdown Training Existing policy not followed Note � may not show this slide. To make it fun, might make it a guessing game, where the audience guesses what the most commonly-cited factors were contributing to WSS. May make a family feud-type poster, where they guess the answers.Note � may not show this slide. To make it fun, might make it a guessing game, where the audience guesses what the most commonly-cited factors were contributing to WSS. May make a family feud-type poster, where they guess the answers.

20. Preventing WSS Incomplete/unclear policies No site verification process in place in imaging, radiology, etc. In OR, surgeon leads pause; in radiology, RN leads pause Xray staff did not know site verification policy Lack of understanding of need to indicate laterality externally for endoscopic procedures

21. Preventing WSS Chaos/confusion/distractions Different types of procedures done in single space, leading to chaotic environment Anesthesiologist and CRNA became distracted and did not conduct time out No �cue� to focus team for final pause Non-OR environment can have too much noise to allow focus on procedure/protocol

22. Preventing WSS Cultural Issues Radiology staff trusted MD and did not speak up Technician�s role not clear Everyone trusted each other and assumed things were correct � no pause Staff didn�t know how to get MD attention about possible WSS without alerting patient MD disregarded request to mark site per policy

23. Preventing WSS Visibility of site marking Mark obscured by betadine prep Site marked with ballpoint pen, not visible during pause Site marked with a dot rather than initials Patient repositioned after site marking

24. Preventing WSS Other Not all staff participated in time out Electronic medical record makes procedure difficult to find; errors can happen if computerized system used instead of consent to verify Anesthesiologist working alone did not do pause before regional block High demand for procedure room leads to time pressures Not all staff trained on protocol; documentation not developed for non-OR settings Facility did not reinforce that protocol needs to happen EVERY TIME