Worst-case surgery scenario: Surgery begins, goes well, and the patient is wheeled into recovery. Later, the ASC learns the patient underwent the procedure at the wrong surgical site.
Wrong site, wrong procedure, and wrong patient surgery problems consistently have an underlying factor: poor communication between healthcare professionals, according to the Patient Safety Network (PSNet) of the federal Agency for Healthcare Research and Quality (AHRQ). (More information on PSNet can be found at: http://bit.ly/2pPdNiR.)
“There are lots of ways for a breakdown in communication,” says Ann Shimek, MSN, BSN, RN, CASC, senior vice president of clinical operations at United Surgical Partners International (USPI), based in Addison, TX.
Physicians, staff, anesthesiologists, and the scheduler must communicate about the patient during the multiple handoffs, Shimek says.
A technique that confirms communication that is thorough and can improve handoffs is ISBAR, which is:
I – Introduction, identify;
S – Situation: describe the situation;
B – Background: share the background, including allergies and medical history;
A – Assessment;
R – Recommendation.
“ISBAR is a way to confirm you’re meeting all those components to ensure we’re doing the appropriate handoff,” Shimek says. “It improves care and reduces medical errors.”
ISBAR can be used at every stage of patient-ASC interaction. For example, if the patient is sleeping too long in the recovery room, the nurse can give the physician an update on the patient’s status. The update should provide a full picture of the patient’s situation, she explains.
Most medical errors could have been averted through communication. For instance, a medication was ordered and it never arrived in time for a procedure. This backorder issue becomes a problem if it hasn’t been communicated to the surgical team before the patient arrives, which might lead to a surgery delay. This would be a communication error, Shimek says.
Communication and a tool like ISBAR also are useful when contacting patients.
“We must make sure we identify what’s important to the patient and their family so we can provide patient-centered care and make sure the patient experience is the best we can make it,” Shimek explains.
Another communication tool that can be used when speaking with patients is AIDET:
A – Acknowledge the patient, greet by name, and make eye contact.
I – Introduce yourself and explain what you’re going to do. “A nurse could say, ‘I’ve been doing this for 15 years, and you’re going to be in good care because I care about my patients,” Shimek says. “It takes introduction to the next level, making the patient feel comfortable.”
D – Duration: How long will surgery last? How long before the patient learns pathology results? “One of the biggest complaints we hear is how we make patients wait,” she says. “Everyone is challenged, so make sure we set those expectations with the patient about how long they’re going to be.”
E – Explanation: “Explain what you’re going to be doing, the steps you’ll take, and who comes in next,” Shimek says. “Make sure they have a good understanding of what you’re doing and why.”
T – Thank you: Thank patients for entrusting their care to your facility, saying, “We value you and appreciate your coming here.”
Communication that follows AIDET can take place at any time.
“When you’re the pre-op nurse and setting expectations, you can do it,” Shimek says. “When the nurse comes in for the IV, she can say, ‘This will take a few minutes, and I’ll use lidocaine.’”
The idea is to explain well enough that patients have a full understanding of the process. It might take having someone sit down with the patient, looking the patient in the eyes, and walking the person through the process — rather than just starting the IV, slamming it in, and walking away, she adds.
Following the AIDET method can provide for a much different provider-patient experience, and it helps to ensure the facility is providing excellent service, as well as quality, Shimek says.
“Everybody should be doing this,” she notes. “That way, we’re making sure the patient is at the center of our communication.”
A third acronym tool is CUS. This one is useful to remember when someone in an ASC sees something wrong in processes or witnesses an error. CUS represents:
C – Concern: Employees might say they are concerned that they have seen something that doesn’t look right. This often is all it takes to get the physician or supervisor’s attention, Shimek notes. But if they don’t see results, they proceed to the next step.
U – Uncomfortable: “Say, ‘I’m uncomfortable,’” she suggests. Using the word “uncomfortable” is less threatening to the listener than saying, “You’re making a big mistake” or “You’re doing that wrong.”
S – Safety: If expressing concern and discomfort are not grabbing attention and resulting in a change, then the person who witnessed the issue should say, “This is a safety issue.” They also can add that the process should be stopped to check the medication or correct whatever error the person witnessed, Shimek says.
“It’s uncomfortable speaking up. People think they’re right, and you think, ‘Maybe I’m wrong,’” she explains. “Everybody in an organization needs to be empowered to speak up anytime about anything that might be wrong.”
Not speaking up can result in tragedy, whereas there should be no recrimination or embarrassment for speaking up and not being correct.
“Maybe it was the right medication dosage,” Shimek says. “We thank the person for speaking up, saying, ‘We have the right medication, but thank you.’”
CUS was developed to give healthcare employees a practical way to intervene when they witness a problem. “If you say you are concerned, it sounds different than saying, ‘You’re giving the wrong medicine,’” Shimek says. “The receiver’s reaction might be ‘Oh, wait. Let me look. Let me check.’ It’s easier on both ends and not so uncomfortable.”
Root cause analyses of medical errors show that even when staff witnessed a problem, they sometimes felt too intimidated to speak up. Or they might fear retaliation, Shimek explains.
“It starts with the culture at the facility, where we need to make sure everyone feels they are supported,” she says. “We are very efficient. Doctors want us to move quickly, so we need to balance that with patient safety.”
Other methods for improving communication include creating a communication board for staff. It might contain updates and changes in policies and regulations. ASCs also can hold a daily huddle in which one person from each department comes together to talk about how surgeries went that day: What went well? Where are there opportunities for improvement?
“Then we look back and see if we have the right equipment and right supplies,” Shimek says. “A responsibility of the team that meets during the daily huddle is to take information and communicate it back to their staff.”
All these methods to improve communication hinge on the surgery center’s culture, she notes.
“It’s about building that culture where everyone feels empowered to speak up,” she says. “If you don’t have that, then none of this will be successful.”
Wrong site, wrong procedure, and wrong patient surgery problems consistently have an underlying factor: poor communication between healthcare professionals, according to the Patient Safety Network of the federal Agency for Healthcare Research and Quality.
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