O T H E R F E AT U R E S Success in Preventing Wrong-Site Procedures in Minnesota with the Minnesota Time Out Diane Rydrych, MA Editor’s Note Assistant Director, Division of Health Policy The Pennsylvania Patient Safety Authority is pleased to report another success in improving Minnesota Department of Health wrong-site surgery from colleagues in Minnesota, who have also undertaken a project to prevent wrong-site surgery in their state. In Minnesota, as in Pennsylvania, wrong-site surgeries and wrong-site invasive proce- dures are issues of great concern. In 2008, Minnesota used a collaborative approach to develop a human-factors-based time-out process known as the Minnesota Time Out. Since spring 2011, an effort has been under way to implement the Minnesota Time Out statewide, with a goal of having every hospital and ambulatory surgery center per- form the specific steps of the time-out for every invasive procedure, every time. During the first seven years in which Minnesota’s mandatory statewide adverse event reporting law has been in effect (2003 to 2010), 155 (11%) of the 1,403 adverse events that were reported to the Minnesota Department of Health by hospitals and ambula- tory surgery centers were wrong-site procedures. The number of reported events in this category increased from 13 in year one to 31 in year seven, with nearly one-third result- ing in a need for additional treatment, in some cases a second corrective procedure. Roughly 45% of these wrong-site procedures occurred outside of the operating room (OR), most commonly in interventional radiology, anesthesia, radiation therapy, and preoperative areas. Data submitted under the adverse event reporting law underwent a thorough review beginning in 2007 that uncovered a number of common system breakdowns that con- tributed to the wrong-site procedures. Despite the existence of nationwide standards such as the Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™, compliance with best practices for prevent- ing wrong-site procedures was inconsistent, with site marking and time-outs present in only about half of all reported events in 2007. Based on these findings, in 2008 the Minnesota Department of Health and the Minnesota Hospital Association (MHA) began working closely with the University of Minnesota’s Center for Design in Health, a research center that works to integrate human factors system design into healthcare work processes, to develop a more rigorous time-out process grounded in human fac- tors principles. Researchers from the Center for Design in Health observed surgeries in eight facilities around Minnesota in 2008 to document weaknesses in preprocedure verification pro- cesses. Their findings were strikingly consistent across observed facilities. Regardless of facility size, geographic location, and procedure type, the team observed the following: — Inconsistent site-marking practices, including cases without site marks, cases in which the site was marked in the OR rather than in preoperative areas, cases in which site marks were removed or obscured, and cases in which site marks were ambiguous or were made without reference to source documents — Inconsistent time-out processes, including cases with no time-out, cases in which team members did not cease other activities or actively participate in the time-out, cases in which information for the time-out was provided from memory rather than with the use of source documents, and cases in which the time-out was done without the surgeon present Based on these observations, the researchers worked with the department of health and MHA to develop a comprehensive preprocedure verification process, the Min- CORRESPONDING AUTHOR nesota Safe Surgery process. The steps in the time-out portion of this process, and the E-mail address: Diane.Rydrych@state.mn.us rationale for each, are outlined in the following discussion. Page 150 Pennsylvania Patient Safety Advisory Vol. 8, No. 4—December 2011 ©2011 Pennsylvania Patient Safety Authority MINNESOTA TIME OUT Association, the Minnesota Ambulatory participating organizations have access to The Minnesota Time Out is a critical Surgery Center Association, and the training, videotaped simulations of the component of the Minnesota Safe Surgery MMIC Group, a medical professional time-out for auditing practice, and other process. Each step of the time-out has liability insurance company. This group of resources, including time-out videos, been designed based on human factors organizations established the Minnesota sample policies and scripts, and talking and cognitive science principles to create Safe Surgery Coalition to address chal- points. To assist in engaging physicians in an effective time-out that engages the full lenges related to prevention of wrong-site the process, MHA developed a “Physician procedure team. procedures and to brainstorm strate- Peer-to-Peer” DVD that features promi- gies for leveraging each organization’s nent Minnesota surgeons talking about IMPLEMENTATION AND resources and influence to push for state- the importance, value, and simplicity of wide implementation of best practices to the Minnesota Time Out. More than DISSEMINATION prevent wrong-site procedures. 100 facilities across the state are currently Since its development in 2008, the Min- involved in the campaign (see Figure). During the spring of 2011, the Safe nesota Time Out has been incorporated Surgery Coalition initiated a three-year While the journey to prevent wrong-site into statewide wrong-surgery prevention campaign to eliminate wrong-site pro- procedures in Minnesota is far from over, work, with the goal of establishing this cedures, with the first year focusing on this concerted statewide effort to sup- more prescriptive, more rigorous time- ensuring that the Minnesota Time Out port implementation of the Minnesota out as the statewide community standard was conducted for every patient, every Time Out is starting to bear fruit. Since (see Table). To accelerate this work, invasive procedure, every time. Each Minnesota began requiring reporting of MHA convened a group that included facility that signed up to participate in wrong-site procedures in 2003, the num- the Minnesota Department of Health, the Minnesota Time Out campaign is ber of days between events has averaged the Minnesota Medical Association, the required to have its chief executive offi- roughly 13. During the first six months Minnesota Medical Group Management cer sign off on this commitment, and of the current reporting year, prior to Table. The Minnesota Time Out STEP RATIONALE 1. Person performing procedure initiates, using a phrase such The team is more likely to cease activity and come together as “Let’s do the time-out now.” for the time-out if it is initiated by the person performing the procedure; the person performing the procedure is the only one who can know when he or she is ready to begin. 2. Team ceases all activity. Active listening and participation: team cannot cognitively engage in time-out if engaged in other activities. 3. Designated staff member, other than person performing Source documents have been verified prior to the procedure procedure (e.g., in the operating room [OR], the and should be an accurate source of information. circulator), verbally states patient name, procedure, and All team members must have an active role in the time-out in location while referring to source documents. In the OR, order to be cognitively engaged. the anesthesia care provider then provides patient name and procedure from his or her documentation. Requiring an active response (rather than “I agree”) from all team members and providing each with an active role counters rote recitation. 4. Designated staff member, other than person performing The site mark has already been verified against source procedure (e.g., in the OR, the scrub staff member), documents; it must be visualized as part of the time-out. locates and verbally confirms visualization of site mark, and states where it is located. 5. Person performing procedure verbally states procedure, Providing information from memory increases focus on the including location, from memory. procedure. The surgeon is the last to verify in order to control for hierarchy or power differential (i.e., if the surgeon states information first, the team is more likely to agree rather than provide independent verification). Vol. 8, No. 4—December 2011 Pennsylvania Patient Safety Advisory Page 151 ©2011 Pennsylvania Patient Safety Authority O T H E R F E AT U R E S Figure. Minnesota Time Out a number of key lessons about how to develop and implement process changes within and across organizations, as well as lessons about the sometimes hidden barriers to change that often derail safety campaigns. The process has highlighted, once again, the importance of clear leadership expectations and standards, particularly for surgeons, in conducting the time-out. It has also shown that a prescriptive process can be successful, as long as those who are carrying it out are well-versed in the rationale for the steps, know what to look for when auditing the process, and have the authority to speak up when the process is not being fol- Reprinted with permission from the Minnesota Department of Health. lowed. These key lessons can offer insight into not only how to design a comprehen- sive safe-surgery process, but also how to engage organizations and team members the launch of the time-out campaign, the 20% reduction in these serious—and to successfully implement and sustain the average number of days between events preventable—events. key best practices that will have an impact was 11, and the state was on track for Time will tell whether this reduction will on outcomes. another increase in the annual number of be sustainable, but Minnesota’s experience events. In the latter half of the reporting For more information about the in working to establish a consistent and year, the average number of days between Minnesota Time Out and the Minnesota effective time-out process as the statewide events has risen to roughly 30, and Min- Safe Surgery Coalition, visit http://www. community standard in hospitals and nesota is on track to achieve a roughly mnhospitals.org/index/timeout. ambulatory surgery centers has provided Page 152 Pennsylvania Patient Safety Advisory Vol. 8, No. 4—December 2011 ©2011 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 8, No. 4—December 2011. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2011 by the Pennsylvania Patient Safety Authority. 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