Battling Wrong Site Surgery Rhonda L Anders MSM

Battling Wrong Site Surgery Rhonda L. Anders, MSM, BSN, RN, CNOR, NE-BC Director, Perioperative Services Franciscan St. Francis Health Indianapolis, IN November 18, 2013

Rhonda Anders, MSM, BSN, RN, CNOR, NEBC RHONDA ANDERS HAS BEEN A PERIOPERATIVE REGISTERED NURSE FOR 23 YEARS AND HAS FULFILLED THE FOLLOWING ROLES: STAFF NURSE, CLINICAL EDUCATOR, CLINICAL MANAGER, AND PERIOPERATIVE SERVICES DIRECTOR. AS SHE PROGRESSED THROUGH THE VARIOUS STAGES OF HER CAREER, SHE RELIED MORE HEAVILY ON EVIDENCE-BASED PRACTICE AND ENGAGEMENT WITH AORN. SHE SERVED AORN ON THE NATIONAL BOARD OF DIRECTORS FROM MARCH 2007 – MARCH 2011. SHE HAS PREPARED AND PRESENTED DOZENS OF EVIDENCE-BASED PRESENTATIONS RELATED TO SAFETY IN THE PERIOPERATIVE SETTING.

Disclosure Information Speaker: Rhonda Anders, MSM, BSN, RN, CNOR, NEBC Discloses no conflict Planning Committee: Ellice Mellinger MS, BSN, RN, CNOR Discloses no conflict AORN’s policy is that the subject matter experts for this product must disclose any financial relationship in a company providing grant funds and/or a company whose product(s) may be discussed or used during the educational activity. Financial disclosure will include the name of the company and/or product and the type of financial relationship, and includes relationships that are in place at the time of the activity or were in place in the 12 months preceding the activity. Disclosures for this activity are indicated according to the following numeric categories: 1. Consultant/Speaker’s Bureau: 2. Employee 3. Stockholder 4. Product Designer 5. Grant/Research Support : 6. Other relationship (specify) : 7. Has no financial interest: None Accreditation Statement AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. AORN IS PLEASED TO PROVIDE THIS WEBINAR ON THIS IMPORTANT TOPIC. HOWEVER, THE VIEWS EXPRESSED IN THIS WEBINAR ARE THOSE OF THE PRESENTERS AND DO NOT NECESSARILY REPRESENT THE VIEWS OF, AND SHOULD NOT BE ATTRIBUTED TO AORN. 4

Learning Objectives • Catalogue early attempts at preventing wrong site surgery • Analyze the impact of culture on wrong site surgery • Compose tactics for the prevention of wrong site surgery

Battling Wrong Site Surgery

Introducing Time Outs: Our Primary Weapon January 2003 National Patient Safety Goals 1. To improve the accuracy of patient identification by using two patient identifiers and a time out procedure before invasive procedures 2. To eliminate wrong-site, wrong-patient, and wrong procedure surgery using a preoperative verification process to confirm documents, and to implement a process to mark the surgical site and involve the patient/family Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries. AORN Connections, 5 -6

The Joint Commission 2004 Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery Key Defenses in the Battle: v. The Time Out v. Preoperative Verification Process v. Marking of the Operative Site

AORN’s 2004 Contributions to the Battle Correct Site Surgery Tool Kit National Time Out Day Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries. AORN Connections, 5 -6.

TJC’s Center for Transforming Healthcare Adds to Our Arsenal 2009 Wrong Site Surgery Project v. Booking Errors v. Verification Errors v. Errors Caused by Distracting or Rushing v. Elements of the time out not verbalized v. Inconsistent Site Marking v. Lack of a Fully Functioning Safety Culture Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries. AORN Connections, 5 -6

Targeted Solutions Tool for Wrong Site Surgery February 2012 Developed from Findings of the Wrong Site Surgery Project: v Guides healthcare providers through a step-bystep process to assess their vulnerabilities v Risk begins as the case is booked due to variations in processes v Identifies specific risk factors unique to each organization v http: //www. centerfortransforminghealthcare. org/ De. John, P. (2012). Joint Commission tools to prevent wrong surgery. OR Manager, 1 -3.

All These Weapons Have Reduced Wrong Site Surgery in the United States False

US Department of Energy (DOE) Guiding Principles of Safety Leadership Commitment is Essential for Creating a Culture of Safety • Senior managers demonstrate their commitment to safety in both word and action • • Patient safety leadership walk rounds Safety Attitudes Questionnaire Birnbach, D. J. , Rosen, L. F. , Williams, L. , Fitzpatrick, M. , Lubarsky, D. , & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233 -240.

Safety Attitudes Questionnaire Courtesy of Pascal Metrics, Inc. 2013.

US Department of Energy Guiding Principles of Safety Everyone is Responsible for Safety • Regardless of position or level within the organization, everyone must be empowered to raise safety issues or question an action that compromises safety • The ability of staff to raise concerns influences safety Birnbach, D. J. , Rosen, L. F. , Williams, L. , Fitzpatrick, M. , Lubarsky, D. , & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233 -240.

Safety Attitudes Questionnaire Courtesy of Pascal Metrics, Inc. 2013.

US Department of Energy Guiding Principles of Safety Empower Governing Bodies to Create and Enforce Safety Policies Defense Nuclear Facilities Safety Board (1988) Agency for Healthcare Research and Quality (AHRQ) v v Called for a single national healthcare safety body to coordinate standards and deliver widespread communication regarding safer health care policies v Tubing and catheter connection errors: brought forth the need to standardize safety approaches with connections v v Congress charged this independent oversight organization to develop meaningful safety standards ensure consistent requirements for management and contractors raise technical competence to ensure protection of workers and the public Created industry wide process to review, identify, and prevent hazards and share best practices to improve safety Birnbach, D. J. , Rosen, L. F. , Williams, L. , Fitzpatrick, M. , Lubarsky, D. , & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233 -240.

US Department of Energy Safety Standards Eliminate Preventable Harm • • Injuries are preventable • Injuries, events, and accidents are not tolerated • Learning mentality for prevention and improvementinvolves critique, investigation and correction. DOE sets the safety goal to ZERO Identified Defect, or near miss identified by front line staff, dated, and placed on this section of the Learning Board In Progress Identified issues placed here when “who” is assigned to address Birnbach, D. J. , Rosen, L. F. , Williams, L. , Fitzpatrick, M. , Lubarsky, D. , & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233 -240. Resolved When the issue is resolved, or problem solved, it is placed here along with a date of completion

Learning Board in Action Identified In Progress Resolved Patient stated, “Total Hysterectomy” while consent stated, “Vaginal Hysterectomy”. No mention of Salpingoopherectomy. What is the meaning of Total Hysterectomy to a patient? Is this a wrong procedure about to occur? Assigned to Quality Manager and OR Manager to determine how to incorporate patients’ verbiage into consent forms to assure that what they believe is about to occur is congruent with what the OR team believes is about to occur. Consent re-designed to prompt additional dialogue free of medical jargon. New consent stresses the importance of understanding what the procedure is in the patients’ own words.

New Language in Consents • Authorization For and Consent to Surgical Operations, Diagnostic and Therapeutic Procedures • Doctor/or designee should write proposed procedure here in the patient’s own words • Please tell me, in your own words, the proposed procedure you are having: ____________________________________________

Learning Board Fighting Wrong Site Surgery at All Levels Identified In Progress Case was scheduled as “left carpel tunnel decompression”. It should have been scheduled as “left carpel tunnel decompression, left cubital tunnel release”. Assigned to Surgery Scheduling Supervisor. Explore documentation of request from Dr. X’s office, examine processes to determine where defect occurred. Resolved

Establish a Universal, Uniform Approach for Safety Management • Integrate safety into all facets of work planning and practices. • Hazards must be understood with preventative controls in place before engaging in any activity • Clear and unambiguous roles and responsibilities are established for ensuing safety. • Use of Checklists Birnbach, D. J. , Rosen, L. F. , Williams, L. , Fitzpatrick, M. , Lubarsky, D. , & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233 -240.

US Department of Energy Guiding Principles of Safety Mandate Reporting of Safety Issues, Errors and Near Misses • DOE views front line staff as most important resource for preventing and reporting hazards and potentially unsafe practices • An effective reporting culture encourages and maintains employees’ open expression of concerns with no fear of retaliation Birnbach, D. J. , Rosen, L. F. , Williams, L. , Fitzpatrick, M. , Lubarsky, D. , & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233 -240.

Mandate Reporting of Safety Issues, Errors and Near Misses Continued • Near misses signal system weaknesses, and because harm did not occur, may provide insight into solutions • Although the national Patient Safety Quality and Improvement Act of 2005 provides confidentiality for reports of medical errors to accredited patient safety organizations, only 27 states require hospitals and/or other medical facilities to report serious medical errors Birnbach, D. J. , Rosen, L. F. , Williams, L. , Fitzpatrick, M. , Lubarsky, D. , & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233 -240.

Identifying Weakness • Repeated reports of missing instruments and instrument set sheet not matching actual contents • • Repeated reports of missing indicators in sets Reports of incorrect packaging for peel packs TROUBLE IN CENTRAL STERILE PROCESSING (CSP)!

Taking Action Before Harm • - - • - Reviewed hours worked by CSP staff No one with less than 90 hours pay for last 3 pay periods. One employee at 153 hours / pay Implemented instrument tracking system required the updating of all set sheets gives us the ability to identify where defects occur in the process Added annual mandatory training to review sterilization indicators and peel packs that go with the different methods of sterilization

US Department of Energy Guiding Principles of Safety Cultivate Learning as Part of the Organizational Mentality v Open trusting environment v Focus on injury prevention v Front line staff freely question processes v Sense of ownership for improving the workplace v Mechanisms such as occurrence reporting, incident investigation, root cause analysis, and self assessments contribute to the learning process. v Medical simulation enhancing learning cultures across healthcare continuum Birnbach, D. J. , Rosen, L. F. , Williams, L. , Fitzpatrick, M. , Lubarsky, D. , & Menna , J. D. (2013). A Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233 -240.

Four Components to the Briefing v. Everyone knows the game plan v. Psychological safety is ensured v. Norms of conduct are discussed v. Expectation of excellence is set Berenholtz, S. , Schumacher, K. , Hayanga, A. , Simon, M. , Goeschel, C. , Pronovost, P. , et al. (2009). Implementing standardized operating room briefings and debriefings at a large regional medical center. Joint Commission Journal on Quality and Patient Safety, 391 -397.

The Briefing Creating Connection with the Patient Is it the gallbladder in room 9…. or… Is it…Our patient Rhonda Anders, - 46 -year old female - Recent history of tibial plateau fracture followed by a series of Deep Vein Thrombosis (DVT) - Currently taking 6 mg of Coumadin daily with an INR of 2. 6 - She’s showing signs of sepsis so we’ve got to get her gallbladder out today - I have no special equipment or instrument needs - But does this information raise questions for any of you?

The Briefing Creating Connection as a Team Surgeon: “Hey guys. ” Staff: “Good morning Dr. Mandelbaum. ” RN Circulator: “Good morning Dr. Mandelbaum. This is Stacy Wilson. She’s a new nurse with us at St. Francis, but not new to the OR” Anesthesiologist, “Hey Jon, how was your trip to Florida last week? ” New employee scrubbed in but never introduced… Or… Stacy RN: “I’ve been in the OR for the past 12 years. Nice to meet you” Anesthesiologist: “You used to work at Methodist, didn’t you? I thought I recognized you” Dr. Mandelbaum: “If any of our equipment or supplies look foreign to you, be sure to ask your preceptor or me for information”

Debriefing is the element that links teamwork and improvement Berenholtz, S. , Schumacher, K. , Hayanga, A. , Simon, M. , Goeschel, C. , Pronovost, P. , et al. (2009). Implementing standardized operating room briefings and debriefings at a large regional medical center. Joint Commission Journal on Quality and Patient Safety, 391 -397.

The Debriefing Creating a Learning Organization Surgeon: “Thanks everybody. Go ahead RN Circulator: “Let’s do the debriefing now. What and get the next patient into the room as went well today? ” soon as you can. I’m going over to 3 West for a few minutes to round. ” Surgeon: “Everything from my perspective, you guys Staff: “Okay, we’ll page you when the patient is in the room. ” Anesthesiologist: “See you in about 20 minutes, okay…? ” Or… did a great job, thanks. Stacy, nice job! Was there anything you would have liked to have been different? ” Scrub: “The lap chole set had a hole in the wrapper. Can you write up a defect sheet and request that this set go into a rigid container. ” RN Circulator: “Will do. Is there anything we should do differently next time? ” New Staff Member Stacy RN: “Yes, I didn’t know Dr. Mandelbaum’s special instruments. I felt like I was fumbling. Can you go over those with me before the next case. ”

Communicate Clearly The Least Expensive Weapon! v. Structured Communication v. SBAR v. Situation v. Background v. Assessment v. Recommendation v. Repeat Back v. Structured Critical Language

Critical Language A Phrase That Stops the Work • “I need a little clarity” • “I am concerned” • “I am unclear” • “This is unsafe”

Stopping the Work Surgery Attendant (SA) arrives at entrance doors to room 12 with patient. The RN Circulator sees the patient and says, “Stop! I have a concern I need to address. ” To SA and Patient, the RN Circulator says: “I’ll be right out to explain. ” • Rooms 12 and 14 were doing Total Joint Jump Rooms • Room 14’s patient was about to be brought into Room 12 • They were both having total hip replacements, but on different sides. What if…

Environment Rife with Embarrassment or Psychological Safety Embarrass: Psychological Safety: v. Feel self-conscious or ill at v. A belief that one will not be ease humiliated or punished for v. Have your composure speaking up with ideas, disturbed questions, concerns, or v. Feel uncomfortable because of mistakes shame or wounded pride v. A shared sense of psychological safety is a critical element in an effective learning system Edmondson, A. (1996). Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, 350 -383.

Do You Have to Protect Your Image at Work? To Protect One’s Image: If you don’t want to look… • Don’t ask questions • Don’t ask for feedback on your performance NEGATIVE • Don’t look doubtful or criticize DISRUPTIVE • Don’t suggest anything innovative STUPID INCOMPETENT • Edmondson, A. (1996). Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, 350 -383.

Psychological Safety to Question the Status Quo Stupid l a ic g o l Incompetent o h ety c y af s Negative P S Disruptive • • Ask Questions Ask for Feedback Be Doubtful Be Innovative Edmondson, A. (1996). Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, 350 -383.

The Fight Continues… Use ALL Weapons at Your Disposal Time Out Preop Verification Site Marking Checklists CSS Tool Kit National Time Out Day Targeted Solutions Tool Briefing Skilled Communication Debriefing Learning Culture Psychological Safety

References Pascal Metrics, Inc. 2013

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