Consider the patient who was scheduled to undergo a procedure to remove kidney stones from the right side. The surgeon performed the procedure on the left side by mistake — and still found a kidney stone, which the surgeon removed.
In recovery, the patient complained about persistent pain on the right side. The nursing staff could not understand why. When a nurse contacted the surgeon, he realized the mistake. Eventually, the patient underwent another procedure to remove the kidney stone on the right side.
Fortunately, the surgery site had a plan in place for handling errors, and they quickly communicated the problem to the patient in a way that helped maintain confidence.
Mistakes and near-miss errors occur in every healthcare setting. With proper planning, surgery professionals can minimize adverse events and react appropriately if they do occur to prevent the situation from spiraling out of control. Sandra Jones, CASC, CPHRM, CHCQM, chief executive officer of Ambulatory Strategies, Inc. in Dade City, FL, outlines tactics to help surgery professionals create the right atmosphere:
• Create a safe space. The first step is to create a nonjudgmental atmosphere in the surgery center. If a mistake occurs, staff should feel safe about timely reporting.
“The report is a way to look at what was going on at the time of the event and to look at the systems or processes in place,” Jones says. “It’s not to point fingers or find fault with anybody; the emphasis on the system is important.” Employees should not be afraid to report problems. They should not try to cover up mistakes. Instead, staff should be fastidious when reporting information about an error. No one should speculate.
• Make a plan. When adverse events occur, staff should know who to report to and how, along with understanding expectations on timeliness. If it is a severe adverse event, sequester equipment, do not throw out trash, and do not empty any syringes.
Explain who speaks to the patient and who has to make the report. Identify what staff members have to do to resolve grievances or complaints. Script a reply to patients who may be voicing a complaint that could turn into a malpractice issue.
When planning, consider government regulations. For example, some states require a physician tell a patient about an adverse event, even if the physician was not involved. “Some states don’t say who needs to tell, but the patient needs to be aware of the adverse event,” Jones says.
National organizations are valuable resources when creating these plans. For instance, the Agency for Healthcare Research and Quality offers modules, videos, sample forms, and PowerPoint presentations on how to deal with communication of errors and patient safety.
• Identify a good communicator. When an adverse event happens, the best person to speak with the patient is someone leaders have identified as a great communicator. This person could be a physician, nurse, director, or anyone with excellent communication skills and who can gain people’s trust.
“You can practice scenarios and choose the person who will have that conversation, and it might not be an administrator or director,” Jones explains. “It could be someone who is a super communicator and who can defuse anger and frustration.”
Good communicators gain confidence by telling patients what the facility plans to do about it. “Usually, you will know who is the communicator because she’s that person who will coach underperforming staff members without hurting their feelings,” Jones observes. “These are people who have good communication skills, good listening skills, and know how to approach a difficult subject.”
• Know when to contact a malpractice carrier. If there is a serious adverse event, the big question is whether malpractice insurance carriers need to be notified and involved.
“Do they need to help guide discussions?” Jones asks. “An investigation may have to include a malpractice attorney. What is discussed can be part of client-attorney protected information.”
The internal investigation should include an analysis and a search for the root cause. When digging deep into root causes, follow the Five Whys rule: “You keep asking ‘why’ until there are no more whys, and you can see what you need to do to not go down the wrong path again,” Jones explains.
• Assess track records. Risk management includes collecting data on near-misses and anything that was not planned or is out of the ordinary.
Surgery leaders could collect information about each member of the team’s track record with errors and assess whether there are people with more frequent mistakes.
“I know one surgery center that believed one physician was bipolar, and when he was off his medication he had more complications. There was a discussion on how to control that,” Jones recalls. “You should look at complications and transfers to the hospital and medication errors. Look at the stuff the staff is indicating about how that person has some health issues that are leading to increased complications or injuries. Your staff need to be reassured that they can speak up.”
• Track medication errors. If the patient is allergic to a drug that was administered, the physician may give the patient a different medication to counter the reaction.
“Tell the patient, ‘We gave you this drug, so if you have any symptoms, alert us right away,’” Jones says. “Or, they could say, “We’ll keep you here a little longer.’” Regardless, both the patient and family need to be informed of such an event.
• Determine solutions. Perhaps the solution is simple — for instance, adding a barrier (e.g., a time-out before the first surgical cut). This ensures no one makes a cut until everyone confirms the correct part of the body.
Regardless, if staff believe there is a problem or potential issue, they need to speak up. “Your staff needs to be aware that it’s their duty to provide safe care. If an intervention needs to occur, then they shouldn’t hide that information,” Jones says.
• Focus on systemic fixes. There are several ways to solve any problem. The weakest one is to educate the staff member involved in the adverse event and tell him or her to do it right the next time.
“If you have a systemic problem, the mistake will be repeated because it’s not just one person’s problem,” Jones explains. “Look to see what can keep you from going down the wrong road. For some situations, it may be to write a better policy and to educate the staff; for others, it could be to establish another barrier.”
Think of barriers as safety features, like how a microwave will not start unless the door is closed. “Your car won’t go into gear until your foot is on the brakes, and your seatbelt rings until you fasten it,” Jones says.
In an ambulatory surgery center, a good example is eye shields. Perhaps surgeons are working only on one eye. Before the operation, staff might ask the patient to identify which eye is undergoing the procedure, and check that response against information in the chart. “Then, [staff] say, ‘I’ll put this shield over your right eye so it won’t be in the way when we work on your left eye. Then, you can take the eye shield home and put it over your left eye to protect it when you sleep,’” Jones offers.
Through a combination of questions, verbal cues, and fact-checking, this surgery center is ensuring the patient undergoes the right procedure on the proper eye.
Any surgery center can establish their own barriers. These can be creative solutions. For example, Jones knows of an orthopedic surgeon who once performed surgery on the wrong knee.
After that experience, he established a rule of putting a compression stocking on the nonoperative knee of every knee surgery patient.
“The compression stocking confirms that the surgeon is operating on the correct knee,” Jones says. “Even if the patient is turned over, the surgeon is not going to cut through a compression stocking.”
Mistakes and near-miss errors occur in every healthcare setting. With proper planning, surgery professionals can minimize adverse events and react appropriately if they do occur to prevent the situation from spiraling out of control.
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