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What’s New in Safety in the OR?. Keith P. Lewis, R.Ph., MD Professor and Chairman Department of Anesthesiology Boston University School of Medicine June 10, 2014 8:00-9:00 AM. Why Do Accidents Happen?.

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What’s New in Safety in the OR?

Keith P. Lewis, R.Ph., MD

Professor and Chairman

Department of Anesthesiology

Boston University School of Medicine

June 10, 2014

8:00-9:00 AM


Why do accidents happen
Why Do Accidents Happen?

Accidents appear to be the result of highly complex coincidences which could rarely be foreseen by the people involved. The unpredictability is caused by the large number of causes and by the spread of information over the participants...accidents do not occur because people gamble and lose, they occur because people do not believe that the accident that is about to occur is at all possible.

Wagenaar and Groeneweg, Best Medicine


Lucian leape md
Lucian Leape, MD

Everyone makes errors everyday

No one makes an error on purpose

An error is not misconduct

We make errors for a reason


Why do errors occur
Why Do Errors Occur?

Interruptions

Fatigue

Multi-tasking

Failure to follow-up

Poor hand-offs (hand-overs)

Ineffective communication

Workload fluctuations


Harvard closed claims review
Harvard Closed Claims Review

Ten years of closed OB claims from Harvard hospitals

2-3 reviewers

Structured review form

Consensus required

Most common team-related deficiencies

Failure to cross-monitor: 76%

Poor communication:67%

42% of cases could have been prevented or mitigated with better teamwork


Teamwork is a solution
Teamwork is a Solution

It is the unidentified, uninterrupted error that may cause harm.

Professionals trained in team behaviors are prepared to recognize, manage, and/or mitigate the impact of an unfolding error.

- Team Performance Plus


Potential crises
Potential Crises

Anaphylaxis

Transfusion Reactions

Malignant Hyperthermia

Difficult Airway

Fires

Electrical Safety

Cardiac Arrest

But what do they have

in common?


Recognition, Management, and Prevention

of Specific

Operating Room Catastrophes

Presented at the American College of Surgeons 89th Annual Clinical Congress,

Chicago, IL

Christopher R. McHenry MD, Ramon Berguer MD, FACS, Rafael A. Ortega MD

Journal of the American College of Surgeons

Volume 198, Issue 5 , May 2004, Pages 810-821

It’s Everyone’s Business!


Features in common
Features in Common

Critical incidents

Reason’s Swiss Cheese

Relatively Rare

Training (and re-training) Required

Communication issues

Fixation Errors

Reportable events

Litigation Prone


What is a critical incident
What is a “Critical Incident”?

Term made famous by Cooper

Defined: Occurrences that are “significant or pivotal, in causing undesirable consequences

Also defined as: An event that led, or could have led to a problem

Critical Incidents provide opportunity to learn about factors that can be remedied

Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978 Dec;49(6):399-406.


t

Reason’s Swiss Cheese

Successive Layers of Defenses

Unsafe

Acts

Precondition for

Unsafe Acts

Unsafe

Supervision

Organizational

Influences

Based on: Reason, J. (1990) Human Error. Cambridge: University Press, Cambridge


Aligned Holes

Example: wrong site / wrong patient

Failed or Absent

Defenses

Based on: Reason, J. (1990) Human Error. Cambridge: University Press, Cambridge


System Failure

Based on: Reason, J. (1990) Human Error. Cambridge: University Press, Cambridge


Recommendations

Analyze all critical incidents, including the ones that could have led to a problem

Use a standardized approach to identify causes, system failures, and opportunities for improvement.

Where was the “hole” in the Swiss cheese?


Cardiac Case

“Eight thousand of heparin”

vs.

“A thousand of heparin”

Communication Error


Communication challenges
Communication Challenges

Language barrier

Distractions

Physical space

Personalities

Workload

Varying Communication Styles

Conflict

Lack of Verification of Information

Shift Change/Handoffs


Communication is
Communication is…

The effective and accurate transfer of information from one provider to another

More than simply speaking

The responsibility of both the sender and receiver to ensure that the information has been transferred


Communication is the response you get to a message you sent regardless of the intent anonymous
“Communication is the response you get to a message you sent regardless of the intent” (anonymous)

Words account for 7% of message*

Tone of voice accounts for 38%

Body language accounts for 55%

*Mehrabian 1971


Stairway of Communication sent regardless of the intent”

Done

action

Understood

X

X

X

X

Not said

Not done

Not understood

Heard

Not heard

Said

Meant

Closing the loop

Modified from Miller’s Anesthesia. Elsevier 2009


Standards of effective communication
Standards of Effective Communication sent regardless of the intent”

Complete

Brief

Clear

Avoid jargon (e.g. prohibited abbreviations)

Timely

Directed at an individual

Verified


Communication Error sent regardless of the intent”

Standard practice in the military, esp. in the Navy, is to use “voice procedure” to maximize clarity of spoken communication and reduce misunderstanding.

Control Room aboard USS Seawolf submarine. (courtesy of www.navy.mil)


Recommendation
Recommendation sent regardless of the intent”

  • Use Closed-Loop Communication whenever possible.


The ether screen
“The Ether Screen” sent regardless of the intent”


Transparent Drapes sent regardless of the intent”

Transparent Ether Screens: The Road to New Transparency

Ortega R, Gonzalez M, Lewis K

ASA Newsletter , February, 2010


The Missing Kidney sent regardless of the intent”

In December 1954, Dr. Murray performed the world's first successful kidney transplant between the identical Herrick twins at the Peter Bent Brigham Hospital.


ETT sent regardless of the intent”

Foreign Body

Anesthesia

Machine

Ascaris

ETT

Kinking

ETT

Defective

Severe

Bronchospasm

Chest Rigidity

Turbinate

Avulsion


Safety Trumps Efficiency sent regardless of the intent”


Is it ok to proceed
Is it OK to Proceed? sent regardless of the intent”

match

risk

waste

match

Preparedness

Complexity


Most Departments sent regardless of the intent”

Preparedness

Complexity


Preparedness sent regardless of the intent”

Complexity

Ideal Department


Ok model card
OK Model Card sent regardless of the intent”


Airway PREPAREDNESS sent regardless of the intent”

Complexity

Small chin

Short neck

Obese

Goiter

MP lV

Normal

MP l

Small chin

Short neck

MP lll

Small chin

MP ll

Preparedness


Recommendation sent regardless of the intent”

Use an approach that prompts matching preparationwith the complexity of the challenge ahead.


Application of ok to proceed
Application of OK to Proceed sent regardless of the intent”

Retained Foreign Body

Wrong Site Surgery


Retained foreign body
Retained Foreign Body sent regardless of the intent”

Axial CT of face showing foreign body in right TM joint region

Agarwal et al., Otolaryngology 2013, 3:3


Retained foreign bodies
Retained Foreign Bodies sent regardless of the intent”

Incidence: 1/8001 to 1/18,760

Final Instrument Count Often Correct

Never Event

Devastating for the patient: Infection, abscess, need for additional surgery


Assess complexity before your proceed
Assess COMPLEXITY Before Your Proceed sent regardless of the intent”

  • Know Risk Factors

    • Multiple Surgeons Present

    • BMI >40

    • Rapid Closure/Changed Procedure

    • Procedure Done Different from Original Plan

    • Multiple Team Changes

      NEJM 2003;348:229-35


Add levels of preparedness
Add Levels of PREPAREDNESS sent regardless of the intent”

Part of Universal Protocol

Mandate X-ray for High Risk Procedures

Manual/Visual Inspection of the Cavity

Notification of Location on Field

Retained Foreign Body Alert

Train and Educate the Radiologist

Avoid CUTTING pledgets


Wrong site surgery
Wrong Site Surgery sent regardless of the intent”


Wrong site surgery1
Wrong Site Surgery sent regardless of the intent”

  • Incidence: 1/112,000

    • Per year in a 300 bed hospital

    • Wrong-side arthroscopy: $450,000

      Wrong cervical disc: $1,175,000

  • Its PREVENTABLE

  • National Quality Forum – Never Event

  • Joint Commission – Sentinel Event

    Ann Surg 2007;246:395-405


Joint commission s evaluation of 126 cases
Joint Commission’s Evaluation of 126 Cases sent regardless of the intent”

Orthopedic 41%

General Surgery 20%

Maxillofacial, CV, 14%

Oto, Ophthalmology

Urology 11%

All Others 14%

Ambulatory (58%), Inpt OR (29%), ER/ICU (13%)

Sentinel Event Alert 2001;Dec 5:24:1-3


Wrong site surgery in otolaryngology head and neck surgery
Wrong Site Surgery in Otolaryngology-Head and Neck Surgery sent regardless of the intent”

  • Medline database 1980-2013

  • 0.3%-4.5% of all wrong site surgery events

  • Wrong site surgery accounts for 5-6% of OTO medical errors

  • 9-21% of otolaryngologists report experience with WSS

  • Major issues: Inverted imaging and ambiguity on site marking

  • Temporary injuries with few cases of permanent disability or death

  • Future: Standardized protocol to confirm imaging accuracy and specialty or procedure specific checklist

    Liou T, et al. Laryngoscope, May 2013


What are the system breakdowns
What Are The System Breakdowns? sent regardless of the intent”

Not verifying consent or site markings

Surgeon specifying the wrong site

Not completing a PROPER TIMEOUT

Inaccurate consents/diagnostic reports/images

Patient positioning (either concealing mark or promoting site confusion)

Anesthesia interventions prior to Timeout


Complexity what are the risk factors
COMPLEXITY: What Are The Risk Factors? sent regardless of the intent”

  • Unusual physical characteristics/equipment

    set up

  • Multiple procedures/multiple surgeons

  • Surgeon characteristics (left-handed surgeons)

  • Time pressures

  • Permanency of marking

  • Lack of patient/family involvement


For preparedness need a standardized approach
For PREPAREDNESS: Need A Standardized Approach sent regardless of the intent”

Everyone marks the same way with same pen

Always before induction of anesthesia

Always use the preoperative checklist

Always STOP FOR TIMEOUT

Conducted by specific provider


For preparedness need a standardized approach1
For PREPAREDNESS: Need A Standardized Approach sent regardless of the intent”

  • Final Pause Occurs Before Incision

    (“Knife-Check”)

  • Repeat for multiple surgeons

  • Anyone can say Stop (TEAMS work)

  • Verification of discrepancies and resolution

  • Monitor compliance with protocol


The who checklist
The WHO Checklist sent regardless of the intent”

  • Divides the operation into 3 phases

    • Before induction (Sign In)

    • Before incision (Time Out)

    • Before leaving the OR (Sign Out)

  • Aim: “to reinforce accepted safety practices and foster better communication and teamwork between clinical disciplines…it is intended as a tool for use by clinicians interested in improving the safety of their operations and reducing unnecessary deaths and complications.”


Concepts for success
Concepts for Success sent regardless of the intent”

  • Sincere commitment and embraced by surgery, anesthesia and nursing

  • Adapted to local routines and expectations

    • ONE SIZE DOES NOT FIT ALL

  • Identified “coordinator” or “leader”

  • Verbal process

  • Includes the patient whenever possible


Bmc s universal protocol has
BMC’s Universal Protocol sent regardless of the intent” has

81 Boxes


Crisis checklists for the or development and pilot testing
Crisis Checklists for the OR: Development and Pilot Testing sent regardless of the intent”

  • Developed checklists

  • 12 of the most frequent OR crises

  • Evidence-based metrics of essential care

  • Checklists resulted in a 6-fold increase in adherence to critical steps in management

  • Patient harm persists despite QI and patient safety initiatives

    J Am Coll Surg 2011;213:212-219, Gawande



Or scenario
OR Scenario

  • Mandated attendance

  • 2 entire OR teams

  • Delayed start of OR in 2 rooms (9:30 AM)

  • Fire/bleed

  • Robust debriefing

  • 2 sessions/month


Top 10 saves
Top 10 Saves

Air Embolism

Malignant Hyperthermia

Fires

Stent Thrombosis

Pulmonary Hypertension

Critical Aortic Stenosis

Positioning Injuries

Negative Pressure Pulmonary Edema

Apnea

Torsades de Pointe

1


Transformational changes
Transformational Changes

  • New forms of care delivery

    -TIVA, pumps, closed-loop

  • New reimbursement

  • New configuration of skill set

  • Disruptive changes

    -Population based care, full risk care, ACOs, bundled payments, outcomes-based reimbursement

    Those that make things happen, those who watch things happen and those that wondered what happened

    Ellison Pierce



1


1


Airway teams training
Airway Teams Training

A Comprehensive Difficult Airway Team Training and Evaluation: Impact on Staff Education, Patient Outcomes and Patient Safety

Team Training Program in Simulation




Dismantling cultural barriers
Dismantling Cultural Barriers

“Precious as this passion for patients’ interests might be, physician autonomy is not synonymous with quality. For the needed structural and operational changes--performance measurement, process improvement, teamwork--to become mainstream, doctors must accept that to be all-caring is different from being all-knowing or all-controlling”.

Turning Doctors into Leaders

Thomas Lee, HBR, April 2010


Summary

Is it OK to Proceed?

Universal Protocol

Communicate



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