Anesthesia Department Update

1. Anesthesia Department Update Presented by:Allen Bar, MD

2. OR Committee Update • Patient Safety & Quality • Surgical Infection Prevention (SIP) • VTE Prophylaxis • Wrong Site Surgery Collaborative

3. Surgical Infection Prevention BENCHMARK DATA

4. VTE Prophylaxis BENCHMARK DATA

5. Wrong Site Surgery Collaborative Overview • Partnership for Patient Care Health Care Improvement Foundation “Wrong-Site Surgery Prevention” • Collaborative co-sponsored by ECRI, Delaware Valley Healthcare Council, and IBC • Team convened • Baseline Self-Assessment completed • Conducting 10 observations • Identifying Best Practice – what activities correlate with preventing wrong site

6. Current Wrong-Site Surgery Solutions • Pre-op verification with patient • Mark the site • Time-out before incision (Universal Protocol)

7. Wrong Site Statistics for State of Pennsylvania • Statewide - One reported weekly • Average number of days between events – 33 • As of 2007, wrong site surgery can be expected to occur once a year in the operating room of a 300-bed hospital in Pennsylvania • PAH 20,000 total procedures performed/year • One wrong site = 0.005% or 99.995% correct

8. Operating at 99% QualityIs this good enough? • At least 200,000 wrong drug prescriptions each year • 2 short or 2 long landings at major airports each day = 4 crashes/day • 5000 incorrect surgical procedures per week • Unsafe drinking water for almost 15 minutes each day • 50 dropped newborn babies each day

9. Organizations Involved:The Joint Commission – “Sentinel Event”National Quality Forum – “Never Event”WHO Patient Safety Alliance – “Patient Safety Goal” UPHS – “Zero Tolerance”

10. Wrong side Wrong part Wrong procedure Wrong patient 298 (69%) 60 (14%) 39 (9%) 34 (8%) Wrong-Site Surgery Definition & Errors by Type State of Pennsylvania Reported Data

11. Activities of Surgeon in OR Failure of Time Out Activities of Anesth in OR Failure Verify w/ Consent Failure Verify w/ Patient Info Failure Verify w/ Position/Prep 92 (53%) 59 (34%) 29 (17%) 22 (13%) 21 (12%) 20 (11%) Wrong-Site ErrorsImplicated as a Factor State of Pennsylvania Reported Data

12. Observed & Inferred At-Risk Behaviors for Wrong-Site Surgery Verification • Imprecise scheduling • Leaving critical info in office notes • NOT RECONCILING ALL CRITICAL INFO EVERY TIME • Not involving the patient or confused patient • Surgeon not seeing patient pre-op, rushing to start case • Working from memory • Waiting until OR to reconcile

13. Observed & Inferred At-Risk Behaviors for Wrong-Site Surgery Time Out • Anesthesia block without a time out • Final timeout before prepping and draping • Not including the mark in the time out • Not verifying the timeout against critical info • Working from memory • Multi-tasking during the time out • Not participating in the time out • Failing to speak up / ignoring concerns

14. Wrong-Site SurgeryConclusions • Asking the patient does not always prevent a wrong site error • Asking the surgeon does not always prevent a wrong site error • Marking the patient does not always prevent a wrong site error • Doing a time-out does not always prevent a wrong site error

15. Wrong-Site SurgeryConclusions • A single time-out just prior to the incision is a flawed strategy that violates safety principles of redundant checks of operator dependent critical steps and ignores the potential impact of confirmation bias.

16. Preventing Wrong-Site Surgery • All critical documents agree going into the OR • The site marking is accurate and always visible • EVERYONE is engaged in the time out • SURGEON • ANESTHESIA • CIRCULATOR • SCRUB TECH

17. Next Steps for Team • Complete observations - done • Target crucial processes that need improvement • Work with project team to adapt and implement action goals • Increase observations and monitoring