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(Editor’s note: In this first part of a two-part series on medical errors, we tell you about the new emphasis from an accreditation group, professional associations, and government groups. We also tell you about new guidelines on correct site surgery. In next month’s issue, we’ll give you tips on how to use documentation and education to enhance patient safety.)
A U.S. Navy submarine surfaces and hits a Japanese fisheries’ training boat. Nine people are killed, and 26 survivors are found stranded amid the debris. Several contributing factors are identified: Policies and procedures were not followed; there were some servicemen who feared questioning their commanders. With civilians on board, the servicemen were distracted and had an "altered purpose," and the checks and balances didn’t work.
"When you run into an event that is catastrophic, such as taking off the wrong leg — something that really should not have happened — if you look back on that particular day, they had an altered purpose to the day," says Claire C. Yoder, BSN, JD, consultant and partner with Vanot Consulting, Risk Management Services, in Highland Village, TX. Yoder spoke at the recent meeting of the Denver-based Association of periOperative Registered Nurses (AORN) on the topic, Medical Errors: System Solutions for Ambulatory Care.
The altered purpose might be that there were an unusual number of people in the department or late start times, Yoder says. "That’s when you have to be on your highest alert," she cautions.
You almost always have a pre-existing condition or weakness that serves as a warning sign before a same-day surgery disaster, she maintains. "And that’s why you have to pay attention to even the small things that are going on in your busy, busy day," Yoder warns.
Ambulatory surgery is especially vulnerable to patient safety issues because patients are often discharged within a few hours, and often follow-up is not as thorough as it should be, she says. Same-day surgery experts point to the fact that post-op calls are often made the day after surgery; however, infections might not show up for several days.
According to an informal survey that Yoder’s firm conducted of 50 outpatient surgery employees at three facilities (two freestanding and one attached to a hospital), 79% of staff had seen an error made by a physician that caused patient injury; 36% said they were serious or fatal injuries. And about half as many (48%) had seen a nurse make an error that caused patient injury; 15% had seen a nurse error that resulted in serious injury or death. All of the respondents said they had seen only one such error in their careers. "We make the most mistakes in routine things that we do every single day," Yoder says.
Patient safety is moving to the top of the priority list of many same-day surgery managers for the following reasons:
— The Joint Commission on Accreditation of Healthcare Organizations has new patient safety standards that will be implemented for hospitals July 1, 2001. Sources say the standards will be expanded to surgery centers by the end of the year. (For more information on the Joint Commission standards, see Patient Safety Alert, included in Same-Day Surgery, April 2001.)
— A new report from the Washington, DC-based Institute of Medicine report says health care providers should give greater attention to systems that reduce risk and ensure safety.1 (For information on how to access the report, see "Sources" at the end of this article.)
— The AORN has just approved a position statement on correct site surgery, which recommends that each member of the surgical team should verbally verify the correct site. (See "Have process in place for marking surgical site," in this issue.)
— The Health Care Financing Administration (HCFA) plans to require all Medicare providers to have a safety program, according to Kathy Bryant, JD, executive director of the Federated Ambulatory Surgery Association in Alexandria, VA.
Here are some steps same-day surgery programs can take to reduce medical errors:
• Allocate resources for patient safety. The Joint Commission standards require resources to be allocated for patient safety, Yoder emphasizes. "[It is] requiring that you integrate patient safety activities and that you have a proactive error reduction system, she says.
Many same-day surgery managers are unsure how to document the amount money they’ve spent on patient safety, other than showing the education budget, Yoder says. Infection control is one area that you budget for, she points out. Also, "if you get new or better supplies or equipment because they’re safer for the patient, or you do it in response to some risk that’s possible — something’s old and worn out — that’s a patient safety activity," Yoder says.
Many surgery centers have a safety program, but the managers don’t refer to it by that name, Bryant says. "For example, cleaning your sidewalks of snow so someone doesn’t fall and break an ankle, checking shelves for outdated drugs — these are things all institutions do and certainly ambulatory surgery centers, but we might not have labeled it that," Bryant says. "Under the upcoming HCFA requirement, we’ll have to label it that."
As part of your patient safety program, weight your technology purchases toward safer devices, advises Lee Swanstrom, MD, clinical professor of surgery at Oregon Health Sciences University and director of the department of minimally invasive surgery at Legacy Health System, both in Portland. For example, Legacy Health System expedites purchases of energy sources that offer safety advantages to patients.
The cost of new supplies and equipment to reduce needlestick injuries or the increased cost per item can be documented as money spent on safety, sources point out.
• Put a specific person in charge of safety. Appoint a patient safety officer/chief safety officer, Yoder suggests. This position, which can be paid or unpaid, designates one person to monitor safety activities, she says. This position probably will be required under the upcoming HCFA requirements, Bryant adds.
• Expand peer review to nurses. Some states, such as Texas, are requiring a peer review system for nurses, Yoder says. "Peer review involves more than just bringing in the physician or nurse when a questionable event has occurred," she says. Reviewing charts and discussing clinical outcomes are peer review activities, "so the activity should be expanded and not just thought of as a punitive setting," she says.
• Review variations in processes. Physicians often adapt surgical processes to their own particular practice, Yoder warns. "Staff do it one way for one doctor, and another way for another doctor," she says. "They can increase risk, and staff frequently don’t have the process in place to review that," she says. Physicians shouldn’t become defensive when a nurse says, "I shouldn’t do it differently for you," Yoder says. A patient safety officer can mediate, she suggests.
• Empower staff to speak up. While you don’t want members of your OR teams to argue, some programs have gone in the opposite direction and incorporated an atmosphere of silence regarding questionable practices, Yoder says. Pointing to a situation in Tampa, FL, in which the wrong leg was removed from a patient, she says, "some of surgical techs thought things weren’t going right, but they didn’t think it was their place to say so."
• Use simple discharge instructions, and share them with the patient’s family members or friends. "Nurses can get distracted and busy and not do more than hand a piece of paper to someone that can get lost in glove compartment," Yoder says. Patients are often groggy, so with the patient’s permission, involve family members or friends in the discharge education, she advises. "Patients are often distracted in the observation mode of looking for infection and being alert to it," she says. "The quicker you get on top of it, the better your situation will be."
Discharge instructions should be as simple as possible, Yoder says. For example, patients should understand that they will have tender wound sites and redness, she says.
One of the problems with patient safety is that many physicians and nurses don’t feel supported in their work, Yoder says. "They’ve been beaten down in the last few years, beaten down by everyone trying to tell them how to run health care," she says. Attempting to meet all the insurance, government, and other third-party demands has left them overburdened, Yoder says. "This patient-caregiver relationship needs to get back to [top] priority," she says.
1. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC; 2001.
Do you have some innovative ideas for reducing medical errors? Please share them with your peers! Use e-mail your ideas to Joy Daughtery Dickinson, Managing Editor, at firstname.lastname@example.org.
For more information on reducing medical errors in outpatient surgery, contact:
• Kathy Bryant, JD, Executive Director, Federated Ambulatory Surgery Association, 700 N. Fairfax St., Suite 306, Alexandria, VA 22314. Telephone: (703) 836-8808. Fax: (703) 549-0976. E-mail: kbryant@FASA.org.
• Lee Swanstrom, MD, 503 N. Graham St., Suite 120, Portland, OR 97227. Telephone: (503) 288-6167. Fax: (503) 288-3437.
• Claire C. Yoder, BSN, JD, Consultant and Partner, Vanot Consulting, Risk Management Services, 725 Country Glen Court, Highland Village, TX 75077. Telephone: (214) 762-9639. Fax: (972) 317-0626. E-mail: email@example.com.
A free copy of the report, Crossing the Quality Chasm: A New Health System for the 21st Century, is available on the web: www.nap.edu/catalog/10027.html. Click on the words "Open Book, Read" under the image of the cover. At press time, a hard copy could be ordered at a prepublication price of $50. It could be ordered at the web site for a 20% discount. For more information or to order, contact:
• National Academy Press, 2101 Constitution Ave. N.W., Lockbox 285, Washington, DC 20055. Telephone: (888) 624-8373 or (202) 334-3313. Fax: (202) 334-2451. E-mail: firstname.lastname@example.org.