Pennsylvania Patient Safety Advisory Quarterly Update on the Preventing Wrong-Site Surgery Project The most recent update from the Pennsylvania Patient Figure. Pennsylvania Patient Safety Authority Safety Authority shows another 15 wrong-site surger- Wrong-Site Surgery Reports by Quarter ies reported during the fourth quarter of 2008 (see NUMBER Figure). As before, minor adjustments have been made OF REPORTS in prior quarters to reflect new information. Encour- 30 aging trends are appearing, however. The Health Care Improvement Foundation’s Partnership for Patient 25 24 Care Wrong-Site Surgery Prevention Program is a 20 20 21 21 regional collaboration with the Authority to prevent 20 19 19 wrong-site surgery. Begun in March 2008, it has not 17 16 14 15 15 15 16 15 had a wrong-site operative procedure in any of its 30 15 13 participating facilities in three months and has not 11 11 had a wrong-site anesthetic procedure in eight months. 10 11 Authority analysts will continue to monitor the prog- ress and are planning to replicate the initiative in 5 another region. One characteristic of the collaborative is that facilities discussed with each other how they 0 would prevent various scenarios (based on reports Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 submitted to the Authority) from happening and how 2004 2005 2006 2007 2008 they would respond if the scenarios did occur. REPORTS BY QUARTER Survey on Surgical Site Marking Pens and 27 facilities noted the durations of the time-outs. The Techniques median for 227 observations was 1 minute and the Authority analysts will disseminate a survey, to be mean was 90 seconds. Atul Gawande, MD, has stated communicated through the Patient Safety Officers that the aviation industry has a rule of thumb that, of Pennsylvania hospitals and ambulatory surgical to maintain effectiveness, a routine checklist address- facilities, in which operating room (OR) managers ing a single task should take less than 90 seconds to can share their good and bad experiences related to perform (personal communication). Please note that the use of various marking pens and techniques for the Time-Out in the OR Competition includes only marking surgical sites. (For more information about the parts of a time-out script that identify the patient, surgical marking pens, see the article “Surgical Site procedure, and side or site of the procedure. Implant Markers: Putting Your Mark on Patient Safety” in the availability, antibiotic administration, allergies, and December 2008 issue of the Pennsylvania Patient Safety other additions to the Universal Protocol not related Advisory.) Others will be encouraged to contribute by to preventing wrong-site surgery have been eliminated downloading an online copy of the survey and sub- from the time-out scripts. Elements of the time-out mitting their experiences to the Authority. that involve confirmation or documentation not based on conversation have also been eliminated. Please The Time-Out Script Competition send your reviews and comments on any or all compo- The editors have received five script entries for the nents of any or all scripts electronically to the editor Time-Out in the OR Competition (depicted on next at jclarke@ecri.org. An electronic copy of the scripts page). For the first round, the editors will accept can be obtained online from the Pennsylvania Patient open-ended review and comment from all who wish Safety Authority’s Web page on preventing wrong-site to do so. The editors may publish some of the cri- surgery (see below). Please ensure that you link com- tiques in the second round, but will not identify any ments to specific scripts by their numbers. This is your reviewers. The reviewers may make a general com- chance to help shape robust scripts for time-outs. ment on any script or comment on any parts of any The Pennsylvania Patient Safety Authority remains scripts, positively or negatively, but should specifically committed to preventing wrong-site surgery and consider at least three issues: (1) compliance with the welcomes any comments, suggestions, and specific time-out elements of the Joint Commission Universal inquiries from facilities with specific problems or Protocol for Preventing Wrong Site, Wrong Procedure questions concerning wrong-site surgery. Communica- and Wrong Person Surgery™ intended to prevent tions should be directed to John Clarke, MD, FACS, wrong-site surgery; (2) active participation of all the clinical director of the Pennsylvania Patient Safety important members of the operating team; and (3) Authority at ECRI Institute, by telephone at (610) efficiency. Efficiency will be defined as the length of 825-6000 or by e-mail at jclarke@ecri.org. time involved in performing the script. During the regional collaborative to prevent wrong- site surgery, mentioned above, OR managers at (continued on page 35) Vol. 6, No. 1—March 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 33 Pennsylvania Patient Safety Advisory Scripts for Mary Jones (DOB 01/01/1921, MR# 007) Left Total Hip Replacement (Supine Position) Script #1 Script #3 Circulating nurse, holding the informed consent Circulating nurse (to all members of the operating and preoperative checklist (to the anesthesia team): “Let’s do our time-out.” provider): “What is the patient’s name and date of birth?” Circulating nurse, after checking around the room to see that all members of the operating team Anesthesia provider, reading from the patient involved in the patient’s care have stopped what label on the anesthesia record after it has been they are doing and are paying attention: “This is confirmed with the patient’s identification bracelet: Mary Jones (looking at the name bracelet); her “Mary Jones, January 1, 1921.” date of birth is January 1, 1921.” Surgeon: “I concur that this is Mary Jones. I am Circulating nurse, reading directly from the surgi- doing a left total hip replacement in the supine cal consent: “Left total hip replacement.” position.” Circulating nurse (to all members of the operating Circulating nurse (to the scrub technician): team): “Do you agree?” “Do you agree?” Other individual members of the operating team: Scrub technician: “Yes.” “I agree.” Circulating nurse (to the anesthesia provider): Circulating nurse: “The left hip is in the supine “Do you agree?” position and has been marked.” Anesthesia provider: “Yes.” Script #4 Script #2 Surgeon (to all members of the operating team): “Let’s do the time-out.” Circulating nurse (to all members of the operating team): “It’s time for the time-out.” Circulating nurse—after all members of the oper- ating team have stopped what they are doing, have Circulating nurse (to the anesthesia provider): turned off any music, and are paying attention— “What is the patient’s name and date of birth?” reads from the informed consent: “This is Mary Anesthesia provider, reading from the armband: Jones; date of birth January 1, 1921; total hip “Mary Jones and her date of birth is January 1, replacement; left side; supine position.” 1921.” Anesthesia provider, referring to the visible site Circulating nurse (to the surgeon): “What is the marking and available documents: “I verify that intended procedure?” we are doing a left total hip replacement on Mary Jones, medical record number 007.” Surgeon: “A total hip replacement.” Scrub technician, referring to the visible site mark- Circulating nurse: “That information matches the ing: “I see the mark on the left hip. I have set up consent.” for a left total hip replacement.” Circulating nurse (to the surgeon): “What side is to Surgeon, referring to the visible site marking: “I be done?” agree that I am doing a total hip replacement on Surgeon: “The left side.” the left side. Available x-rays confirm the left side. I can see and verify the mark. Knife please.” Circulating nurse: “That information matches the consent.” Circulating nurse (to the surgeon): “Is the site mark visible?” Surgeon: “Yes.” Circulating nurse (to the surgeon): “Do we have the correct position?” Surgeon: “Yes.” Circulating nurse (to the surgeon): “Are relevant x-rays available, labeled, and displayed?” Surgeon: “Yes.” (continued on page 35) Page 34 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 1—March 2009 Pennsylvania Patient Safety Advisory Script #5 Anesthesia provider, reading from OR schedule: Circulating nurse (to all members of the operating “Total hip replacement.” team): “It’s time for the time-out.” The nurse checks that the scrub technician’s, sur- Circulating nurse, looking at consent (to the sur- geon’s, and anesthesia provider’s responses match geon): “Please give me the patient’s name.” the consent before proceeding to the next question. Circulating nurse (to the surgeon): “Please indicate Surgeon, from memory: “The patient is Mary on the x-ray the side the pathology is on.” Jones.” Surgeon, pointing to the fracture on the x-ray Circulating nurse, looking at consent (to the anes- image: “The pathology is on the left.” thesia provider): “What is the name and date of birth on the wristband?” Circulating nurse (to the anesthesia provider): “What position is the patient in?” Anesthesia provider, reading from wristband: “The wristband says ‘Mary Jones, January 1, 1921.’” Anesthesia provider: “The patient is in the supine position.” The circulating nurse checks that the surgeon’s and anesthesia provider’s responses match the consent Circulating nurse (to the surgeon): “Please indicate before proceeding to the next question. the side the mark is on.” Circulating nurse, looking at consent (to the Surgeon, pointing to mark: “The mark is on scrub technician): “What procedure are you set up the left.” to do?” Circulating nurse, looking at consent (to the Scrub technician: “I’m set up for a total hip anesthesia provider): “Which side is listed on the replacement.” schedule?” Circulating nurse, looking at consent (to the sur- Anesthesia provider, reading from schedule: “The geon): “What procedure do you intend to do?” schedule says ‘the left.’” Surgeon, from memory: “Total hip replacement.” The nurse checks that the surgeon’s and anesthesia provider’s responses match the consent. Circulating nurse, looking at consent (to the anes- thesia provider): “What procedure is listed on the Surgeon (to all members of the operating team): “If schedule?” anyone has a concern, please speak up.” (continued from page 33) The Pennsylvania Patient Safety Authority devotes a other organizations. The Authority’s Web page is Web page to educational tools for preventing wrong- http://patientsafetyauthority.org/EducationalTools/ site surgery. Its resources include all the Authority’s PatientSafetyTools/PWSS/Pages/home.aspx. publications on the subject, including Advisory articles, self-assessment tools, sample forms and Also highly recommended is the Minnesota checklists, educational posters and videos, illustrative Hospital Association SAFE SITE Web site at figures and tables, patient-education brochures, http://www.mnhospitals.org/index/tools-app/ and links to companion online information from tool.370?view=detail. Vol. 6, No. 1—March 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 35 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 6, No. 1—March 2009. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2009 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web An Independent Agency of the Commonwealth of Pennsylvania site at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.