Minnesota Safe Surgery Coalition. Coalition Goal: Eliminate Wrong Site, Wrong Procedure and Wrong Patient Events within 3 Years . Members Minnesota Hospital Association Minnesota Department of Health Minnesota Medical Association Minnesota Medical Group Management Association MMIC Group.
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Reports of adverse events involving procedures performed on the wrong site/side/level have been increasing in Minnesota.
Last year, 66% of wrong site procedures were on the wrong side (right vs. left).
The Anesthesia Care Provider inserted the needle to perform an anesthesia block. The patient felt a twitch in their leg and stated that the twitch was on the left side and the surgery should be on the right side. The patient was correct.
No site marking or Time Out had been performed for the block.
Site mark for right stent placement placed on arm and was not visible after prepping and draping. Left stent placement performed.
Site mark was not visualized during the Time Out.
Surgeon consulted on patients in two different rooms. Surgeon performed knee aspiration on incorrect side thinking it was the other patient.
Patient identity was not verified and Time Out was not performed.
Patient consented to left knee arthroscopy. Right leg placed in holder and tourniquet placed. Surgical site had been marked but when initials were not seen on the right leg surgeon thought marked was removed by surgical prep.
Site marked was not visualized during the Time Out.
Patient consent for a right knee arthroscopy. All documents indicated right knee and right knee was site marked by surgeon. Surgeon and nurse put leg holder on left side of table and positioned left leg in holder. Left knee injected, prepped and draped. Time Out conducted and incision made to left knee. When nurse started documentation, she noted that the left knee was intended and informed the surgeon.
Site mark was not visualized during the Time Out. All members of the team were not engaged in the Time Out process.
Developed by University of MN Center for Human Factors Research and Design
Observed 58 procedures across 8 hospitals
All steps of the Time Out must be conducted before every invasive procedure for every patient, every time.
Key areas where a Time Out is not consistently applied across the state:
Blocks and injections prior to OR procedures
Stand alone anesthesia blocks
Interventional radiology procedures
Any person who observes or becomes aware of harmful situation in patient care has the authority and responsibility to speak up and request the process be stopped in order to clarify the patient safety situation.
This person needs to say in a firm, clear and respectful manner: “STOP, I have a patient safety concern.”
Staff are to assertively voice concern at least two times to ensure the request has been heard.
If there is noncompliance to respond to this time out, the Chain of Command process is invoked.
An elderly patient undergoing repair of a hip fracture was prepped for a right-sided procedure, consistent with the consent, history and physical, and a consultation report. During the time out, the surgical team determined that the patient had a left hip fracture, which was then confirmed by x-ray. The procedure was performed on the correct side.
Wrong knee was marked in pre-procedure area. Verification of the site marking against source documents uncovered the discrepancy and correct site was marked and surgery completed.
A Time Out must be completed prior to any invasive procedure across the organization for every patient, every time.
All Time Outs must be completed following the 5 key steps in the Time Out process.
If there are any discrepancies during the Time Out or a step is not completed, members of the team will “Stop the Line” until resolution and agreement by the team.
Staff and physicians will be supported by administration in “Stopping the Line.”