Ten steps for making surgery safer
Simple steps for improvement
Wrong-site surgery: 20 times a week. Wrong surgery on a patient: 20 times a week. Object left in a patient: nearly 40 times a week. Surgical "never events": more than 4,000 times a year. Those statistics were reported in a study published in April in the journal Surgery.1 With such statistics, there will never be a single solution that makes surgery safer.
But David Young, MD, medical director of presurgical testing at Advocate Lutheran General Hospital in Park Ridge, IL, and founder of the surgical consultancy Surgical Directions, has come up with 10 things that could help make a dent in never events and make surgery safer for patients. (For complete list, see box on page 88.)
Some items on the list relate closely to culture and leadership issues, such as having medical directors who have the support of leadership and a just culture that encourages everyone to speak up when something doesn't seem right and to report errors and near misses.
Others require resources that some may not have, such as having a pre-anesthesia testing center staffed by hospitalists. But among Young's must-dos are things that any hospital can implement.
• Have a single way to schedule surgery. This may not seem intuitively to be something that can impact safety, but there is anecdotal evidence that it does work. (For more on surgical scheduling, see story page 89.) At Advocate, that means that there is no scheduling over the phone, says Young. All scheduling must be done via computer or fax to limit errors related to transcription errors. Places can be reserved over the phone, but without confirmation in writing, there will not be a surgery.
• Manage documents. Scheduling and document management go together, Young says. Having a single point of entry for scheduling helps with better document management — there are fewer loose pieces of paper, sticky notes and crumpled faxes to keep track of. Having a system that can convert faxes into computer documents, and that uses information from one sector — say scheduling — to populate other documents is required.
• Make sure your sterile processing is superb. This sounds obvious, but often central sterilization departments are out of sight and out of mind. Be sure the staff are educated and well supervised and make sure there are outcomes related to what they do. For instance, a data dashboard should include the percentage of surgical trays undergoing immediate sterilization and surgical-site infection rates.
• Implement World Health Organization checklists. The lists are available at http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html. And encourage people to speak up if steps are skipped.
Other checklists are also a key part of safe surgery, says Young. A presurgical checklist involves reviewing with patients why they are there, their name, and date of birth. The anesthesiologist will use a checklist to look at issues with nurses such as airway, implants such as pacemakers, and the potential need for transfusions. Anesthesiologists will also talk with the surgeon, using a checklist to go over similar questions as were discussed with nursing, as well as information related to equipment used. The time-out checklist is robust, he says, including information on comorbidities, allergies, and special needs of the patient, as well as what the procedure type is.
• Make error reporting a habit. And don't limit reporting to what has happened. Log near misses, too. This involves creating a work environment where everyone feels safe in speaking up. Aggregate the information, do root-cause analyses, and be transparent about your findings.
• Talk amongst yourselves. The daily huddle is the one thing Young says you should do if you are going to do nothing else. A huddle takes place for every case. Before surgery, the team talks about expectations, special patient needs or concerns, and how they expect things to go, says Alecia Torrance, RN, MBA, vice president of perioperative business operations at Surgical Directions. Post-surgical huddles involve reviewing what went right and what didn't. A final group meeting mid-afternoon involves going over the current day and a look at the day and the week ahead.
These are not necessarily fits or fixes for what ails your surgical department. Young says you can ascertain your specific needs by looking at a few data points. Look at cancellations and delays. Young says if a patient is well-prepared, the surgery will go off as scheduled. If you have a lot of cancellations and delays, it could be due to an issue with documentation, presurgical testing, or scheduling problems.
He also suggests you ask staff members at all levels where they see problems. "If they are engaged and empowered, they will feel free to tell you what they really think," says Young.
Human errors will always occur in a healthcare industry staffed by people, he says. "But we can focus on system errors and put practices in place to minimize them. By giving people tools and empowering them to act and speak up, we can also train people to prevent problems. It is when they have no voice, when they feel they can't say anything to the surgeon because they will get into trouble that you will have ongoing problems."
10 Steps for Safer Surgery
- Single path for surgical scheduling
- Medical Directors with Surgical Services Executive
Committee support
- Pre-Anesthesia Testing Center with standardized
protocols/Hospitalists
- Document Management system for scheduling and
PAT
- Excellent Sterile Processing
- Crew Resource Management
- Implementation of WHO/Safety Checklist
- Daily Huddle
- Error Reporting
- Just Culture
For more information on this story contact:
• David Young, MD, Medical Director of Presurgical Testing, Advocate Lutheran Hospital, and Managing Director, Surgical Directions, Park Ridge, IL. (847) 723-2210.
• Alecia Torrance, RN, MBA, Vice President, Perioperative Business Operations, Surgical Directions, Chicago, IL. Telephone: (312) 870-5600.
Reference
1. Mehtsun WT, Ibrahim AM, Diener-West M et al. Surgical never events in the Unites States. Surgery: 2013 Apr;153(4):465-72.
