I just saw clear evidence of the importance of transparency with regard to the reporting of important adverse events and medical errors. Bear with me through the details, but I will not keep you in suspense regarding the conclusion: The wide disclosure of a "never" event in a blame-free manner resulted in an intensity of focus and communal effort to solve an important systemic problem, resulting in redesign of clinical procedures, buy-in from hundreds of relevant staff people, and an audit system that will monitor the effectiveness of the new approach and leave open the possibility for ongoing improvement. If you ever needed a clear example of the power of transparency, here it is.
Back in early July, a patient experienced a wrong-side surgery in our hospital because the staff failed to carry out the required time-out. We disseminated the story of this event to all staff in the hospital. There was a full investigation of the matter, both internally and by the state DPH, and some immediate improvements were made in our procedures. But the more important work was being done by a Safety Culture Operational Task Force co-chaired by a nurse, a surgeon, and an anesthesiologist, and engaging almost two dozen other people from a variety of disciplines and positions in the hospital. Its charge and mission:
To implement and embed the Culture of Safety at the point of care in Perioperative Services, with an emphasis on teamwork and enhanced communications.
They adopted the following principles of patient safety:
-- Building in redundancies and cross checks
-- Standardization
-- Simplification
-- Forcing functions
-- Empowering the grassroots to lead change
They set forth a number of objectives, the first of which were to assure compliance with the time-out Universal Protocol; to script the time-out; and to design and oversee time-out audits. In so doing, they wanted to review and adopt not only the WHO Safety Checklist, but also to incorporate forthcoming 2009 Joint Commission regulations.
The result is pictured above. The document above is the check list that went into use today for all surgical procedures in our hospital. Not shown above is a corresponding computer screen version of the checklist that will be filled out in real time by the circulating nurse as the time out proceeds.
Responsibilities and the order of events is clearly laid out, even to the point of requiring that any radio in the OR is shut off during the time-out so as to avoid aural distraction. Note the forcing function at the very top of the form: No blades, needles, specula or bronchoscopes can be within reach of the surgeon until the full time-out is completed. Also, a system of "secret shoppers" has been set up to quietly audit compliance with these procedures. These are people from a variety of disciplines who normally work in the ORs who have been given this additional job responsibility.
This material was presented today in interdisciplinary grand rounds attended by about 300 people -- doctors, nurses, surgical techs. The response was enthusiastic, as everyone realized the vast improvement this would make in patient safety. And yet, even at this last moment, there were suggestions from the floor that made the process even better.
And then, I just attended a meeting of our Chiefs of Service and senior administrators. I suggested that this kind of effort and the responsiveness seen by our staff would not have happened if they had adopted the traditional approach to a "never" event -- i.e., a quiet discussion among the leadership with a directive to avoid the problem. The response from the three Task Force co-chairs was unanimous: It was because our leadership had the confidence in our staff to go public with this event that the improvement process took on life and energy.
One of our nurse managers today told me that the American Academy of Orthopaedic Surgeons reports that in a 35-year career, an orthopaedic surgeon has a 1 in 4 chance of performing a wrong-side surgery. Three years ago, people in our hospital might have said, "These things happen." We have now learned that they only happen because we let them happen. We let them happen because of our own silence and fear.
No longer.
16 comments:
Each year millions of dollars go to stunningly complicated medical equipment that serves a tiny fraction of patients. Millions of people go without relatively simple evidence-based care for chronic disease. Where are the quality improvement entrepreneurs? How can we mobilize this energy for the countless compromised medical microsystems waiting for an accident to occur? Now we know it can be done.
The Time Out poster is preventive medicine at its best. It also an example of people at the very base of the totem pole in various disciplines coming together for common good and patient safety. Improvements to this process came from the people who need it the most and so it will be durable and so it will also get done. I have no doubt that "transparency" is what helped this process, how else can we get "Joe the scrub tech", "Jane the OR nurse" and "John the surgeon" and "Jill the anesthesiologist" to come up with this excellent effort if we had just kept things among leadership.
Nice job - and you can believe I read every word. (: I LOVE the secret shopper concept as it most closely replicates the real life situation. At first I was questioning the over-120 day lag time for the root cause process. However, it is clear the task force took the opportunity to address a number of associated issues rather than just strictly the wrong site, and apparently involved frontline personnel, which always takes more time - to say nothing of the IT piece.
My question is, exactly how did the co-chairs feel that going public gave the process "life and energy"? Did this have to do with involving front line workers (who presumably would have only known of the incident through the grapevine otherwise), or because the publicity lent an additional sense of urgency, or what?
Again, very nicely done. Once validated over time by the secret shoppers, perhaps you should look into publishing it somewhere....
nonlocal
While we have successfully implemented the Joint Commission’s mandated “time out” to verify the correct patient, procedure and site on the patient’s body before any surgery begins, it is an ongoing process and perfection has not been achieved. We have also put procedures and check lists in place to eliminate the risk of discrepancy between hand-offs to the different medical teams caring for the surgical patient.
When one of our patients enters the pre-op holding area, the holding nurse asks a series of questions beginning with the patient’s understanding of the surgical procedure about to be performed. The surgeon marks the site on the patient’s body with either his initials or “yes” with an indelible pen.
Then the patient is transferred to the OR and verification from the pre-op team is handed off to the surgical team. Just prior to surgery that team engages in an “active” time out to verify all patient identifiers.
Our policy -- and our main objective -- states that if there is ever a discrepancy during time out, the team must stop, research and correct the discrepancy, collaborating with all parties involved.
But this is a constant effort to educate and reinforce safety standards, especially with new employees, part time workers, etc. And creating this culture doesn’t happen overnight. As is said about many things, it’s marathon not a sprint. So we have to remain vigilant and cautious each time we do surgery.
A small typo: the "i.e." under 'verification of the procedure' should be "e.g." - or (even better) "example: ".
A question: Why copyright this? Why not make it freely available under something like the Creative Commons Attribution Share Alike License?
Why do this after the patient is prepped and draped and ASLEEP? Who better to verify "all of the above" than the patient---why doesn't he/she participate in the Time Out? (i.e. BEFORE induction of anesthesia?) This would also eliminate the risk of an anesthetic followed by a cancelled surgery because of "proper equipment" not being available (a "call out" to the clinical advisor is all well and good, but what if, say, the appropriately sized implant is discovered to be "used up yesterday" and not yet replaced in stock?)
I hope the reason is not because it would inconvenience the attending surgeon to have to be present before the moment he is ready to begin. . .
So what do they do for a stat c-section when every second counts?
Excellent point!! "Why not do the time Out before the induction of anesthesia" Yes the committee did consider this and we are going to move towards Time Outs before induction of anesthesia in 2009. In fact that is what JCAHO wants us to do in 2009. It a great leap forward to being allowed to do this before induction because of all the reasons "anonymous" said. The committee unfortunately did not have enough time to put in place all the culture change, the software fixes, the education of staff and all that stuff before the deadline TODAY Nov 14 2009.
But getting patients to participate (to the extent possible after premedication) in the Time Outs will be our goal and thanks for pointing that out.
Whe the patient's life is in danger we will waive the timeouts and these "waives" will be reviewed by the audit committee
A time-out will not delay the delivery of emergency care. In the case of a stat Cesarean, the required elements of the time-out are able to be accomplished in a matter of seconds. The identity of the patient, the planned procedure, and the type of anesthetic are simply stated, and the surgeons, anesthesiologist, and nurse focus together momentarily to assure that the correct procedure is being performed on the correct patient.
Wow. Just wow.
Takes my breath away.
Actually, it is during emergencies that timeouts and other such procedures are most necessary, because that is when things can be forgotten in the rush to save the patient's life. You just wouldn't believe how many ways there are for things to go wrong. Obviously, abbreviation may be necessary, but when doing such things as transfusing blood, patient identification and other such standard procedures remain paramount.
nonlocal MD
Paul: way cool. Transparency to foster learning applies to every profession, even though there is usually initial resistance to do it. In the energy industry where I work, we are also seeing learning enhanced by transparency and full disclosure of 'what went wrong and why'. I can only encourage you to stay the course on transparency--that's the best way to achieve world class performance.
Tom Botts
Congratulations on the most desirable possible outcome from a safety event.
We recently published the results of a national survey of 1,800 physicians by Bob Wachter at UCSF that was designed to understand their perspectives on the preventability of and organizational readiness for "never events," particularly as it relates to Medicare. View the results by clicking the link below
http://quantiamd.com/player/kttrpny?cid=53
In a previous survey of physicians, we asked how many of them would proactively publish their own clinical performance data to their patients, community, and referring physicians, rather than passively waiting for an external body to publish whatever data they had that represented performance. More than 70% of responding physicians said they would publish their own data.
So perhaps there is something to this transparency thing. Kudos.
As an organization whose first pillar is transparency in health care, The Leapfrog Group applauds the efforts your hospital has taken to be both internally and externally transparent about patient safety in your hospital.
Your willingness to be transparent serves as an example of what we would like to see from all hospital leaders.
Keep up the great work!
Matt Austin
Associate, Leaps and Measures
The Leapfrog Group
What is in place should the surgeon refuse to mark the site? I have seen this too often that a surgeon expects one of the nurses to mark the spot so as to lay blame should something go wrong. It takes the entire team to make this work. I applaud your efforts and especially appreciate the multidisciplinary approach.
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