Surgical Specimen Errors in the Operating Room

Slides:

Advertisements

Similar presentations

MCIC Perioperative Initiative February 14, 2006 Operating Room Briefings.

Advertisements

Implementation of a Surgical Safety Check List

Safe Surgery Saves Lives

Creating a Culture of Safety: Challenges in Ophthalmology James P. Bagian, MD, PE Director, Center for Health Engineering University of Michigan Founding.

Surgical safety is a serious public health issue About 234 million operations are done globally each year A rate of % deaths and 3-16% complications.

Dr. ABDULLAH ABDU ALMIKHLAFY Assistant professor & Head of community medicine department Presented By University of Science & Technology Sana’a – Yemen.

Handoff Communication in Critical Care Can the use of Insitu simulation improve communication and patient safety? Fairview Southdale Hospital Edina, Minnesota.

A Few Notes About This Presentation This presentation is designed to be given to a group of nurses and scrub techs at your hospital. We recommend that.

A Few Notes About This Presentation This presentation is designed to be given to a group of surgeons. We recommend that you hold this type of meeting after.

Webinar 9: Engaging Your Colleagues Continued. Mark Your Calendars For The Patient Safety Symposium Columbia, South Carolina April 24 th – OR Team Training,

ARIEL FLUG, SPT Importance of Quality of Care in the Health Professions.

Human Factors & Patient Safety

Safety Basic Science December 22 nd, Safety Attitudes Questionnaire (SAQ) I am encouraged by my colleagues to report any patient safety concerns.

Safe Surgery 2015: South Carolina Presentation [ Insert Implementation Team Member Names] [ Insert Hospital Name] Insert Your Hospital’s Logo Here.

Using Root Cause Analysis to Make the Patient Care System Safe John Robert Dew The University of Alabama.

Revised for 2013 Shannon Hein RN, CPN(C).  published in the Canadian Medical Association Journal in May 2004  Found an overall incidence rate of adverse.

Patient Safety Culture Measurement and Improvement

321 Genesee Street Oneida (315)

HANYS Teamwork – Technique: Achieving Critical Care Excellence Teambuilding for Critical Care Teams.

Talking to Your Nursing and Surgical Tech Colleagues.

Threat and Error Management in Aviation

Call 3: Background of Each Checklist Item. Topics Covered on the Last Webinar Review of articles that have been written about the impact of the checklist.

A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association September 20, 2015 Executive Briefing Drawn.

Topic 10 Patient safety and invasive procedures. Learning objective The objective of this topic is to understand the main causes of adverse events in.

© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Briefings and Debriefings.

National Patient Safety Goals 2011

To remain compliant with the Accreditation Council for Continuing Medical Education (ACCME®) regulations, it is necessary to disclose to my audience that.

Webinar 3: Baseline OR Surgical Safety Culture Survey.

1 National Patient Safety Goals (NPSG). 2 National Patient Safety Goals – set forth by The Joint Commission Identity patients correctly: – Use at least.

“Use data to shed light, not heat.” Source: Reinertsen JL et al 2007.

Safe Surgery 2015: South Carolina Presentation - Surgeons [ Insert Implementation Team Member Names] [ Insert Hospital Name] Insert Your Hospital’s Logo.

PATIENT- AND FAMILY-CENTERED CARE: Partnerships for Safety & Quality Staff Physician & Resident Physician Toolkit.

The Joint Commission’s 2011 National Patient Safety Goals.

Legal & Ethical Issues. Objectives At the completion of this session the participant will be able to: ◦ Describe the ethical principles associated with.

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 10Safety Concerns in Healthcare.

The Disruptive Physician Federation of State Physician Health Programs 2010 Annual Meeting Doris C. Gundersen, MD Medical Director Colorado Physician Health.

Webinar 3: Baseline OR Surgical Safety Culture Survey.

Patient Hand-Offs Sheri S. Crow, MD, MS Assistant Professor of Pediatrics Critical Care Medicine Mayo Clinic Rochester, MN.

Copyright © 2006 Elsevier, Inc. All rights reserved Chapter 22 Quality Patient Care.

Topic 10 Patient safety and invasive procedures. LEARNING OBJECTIVE The objective of this topic is to understand the main causes of adverse events in.

National Patient Safety Goals (NPSGs)

© Copyright, The Joint Commission 2015 National Patient Safety Goals.

Surgical safety is a serious public health issue About 234 million operations are done globally each year A rate of % deaths and 3-16% complications.

Surgical safety is a serious public health issue About 234 million operations are done globally each year A rate of % deaths and 3-16% complications.

A Few Notes About This Presentation This presentation is designed to be given to an inter- disciplinary group of clinicians. We recommend that you hold.

Effective leadership in airline crews. 2 Good teamwork in aircraft crews (Ginnett) & hospital teams (K-P) Aircraft crewsHospital teams.

National Patient Safety Goals 2008 T he University of Toledo Medical Center Toledo, Ohio.

© 2009 Chris George, RN MS Project Manager MHA Keystone Center for Patient Safety and Quality Keystone Surgery: Improving Perioperative Care in Michigan.

© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Briefings and Debriefings Elizabeth Martinez, MD, MHS Michael Rosen,

Safety culture = shared beliefs and patterns of behaviour that determine how we work together to achieve quality care. Safety culture affects patient.

Medical Center Hospital is a Joint Commission Accredited Organization.

SURGICAL FORMS AND RECORDS. TERMINAL OBJECTIVE: Complete selected forms and records.

Malpractice Insurance Incentive for Operating Room Teamwork Training via Simulation Jeffrey B. Cooper, PhD Center for Medical Simulation & Mass. General.

1 Utilization of Operating Room Simulation and Debriefing to Enhance Surgical Resident Participation in the Surgical Timeout Checklist Edward Dominguez.

Increasing Post-Surgical Debriefing Completion Rate Quality Improvement Study Ambulatory Surgery Center.

QUALITY CARE/NPSG’S NUR 152 Week 16. OBJECTIVES Define quality improvement and the methods used in health care to ensure quality care. State understanding.

National Patient Safety Goals (NPSG) Online Orientation -the purpose is to improve patient safety -the goals focus on problems in health care safety and.

Surgical Public Health:

Stephen M. Powell, MS Principal, Managing Partner

Patient Safety Overview 2014

Fasten your seatbelts: the use of checklists

The Joint Commission’s National Patient Safety Goals

Implementation of a Surgical Safety Check List

What are the attitudes and perceptions of Surgeons and Scrub Nurses towards Surgical Briefing and Debriefing? Pamela Firth, BSc. Golden Jubilee National.

2017 National Patient Safety Goals

Surgical safety is a serious public health issue

Surgical safety is a serious public health issue

Five Month Check-In Call

Presentation transcript:

Surgical Specimen Errors in the Operating Room Improving Quality of Care in Surgical Care Surgical Safety Program MCIC-Vermont

The Race to Improve Safety in U.S. Hospitals Why the hysteria? Institute of Medicine Report U.S. Malpractice Crisis

Industries by Size, Productivity, and Efficiency Where We Stand Industries by Size, Productivity, and Efficiency Low Hotels Airlines Tobacco Quality (error rate) Computers U.S. Postal Service Auto Manufacturing Food Services Health Services High Low High *Source: Advisory Board Company, 2005

How do we know we are safer?

Finding the Sweet Spot A Model for Improving Safety Central Mandate Scientifically Sound Feasible Local Wisdom Makary MA, et al. Patient Safety in Surgery, Annals of Surgery, 2006

Attributes of System Level Measure for Safety Scientifically sound, feasible, important, usable Apply to all patients Aligned with value; encourage desired behaviors Meaningful to front-line staff who do the work

Why do Errors Occur in the Operating Room? Root causes Analysis* *Joint Commission on Accreditation of Healthcare Organizations. Sentinel Events : Evaluating Cause and Planning Improvement. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 1998.

Joint Commission on Accreditation of Healthcare Organizations *Joint Commission on Accreditation of Healthcare Organizations. Sentinel Events : Evaluating Cause and Planning Improvement. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 1998.

Safety and Communication The Hierarchy of the Medicine Safety and Communication

Teamwork in the Eye of the Beholder Makary M, Sexton JB, Freischlag JA., et al. Teamwork in the Operating Room. J Am Coll Surg, 2006

Familiarity with others is a critical component of effective teamwork Aviation Data 74% of all commercial aviation accidents happen on the first day of a crew flying together Review of Major Accidents 1978-1990 NTSB 1994 Safety Study Late or behind schedule: 55% (17-28%) First day of pairing: 73% (7-30%) First flight together: 44% (3-10%) Captain Flying: 81% (50%)

OR Briefing Checklist Time-Out Antibiotics DVT Prophylaxis Instruments and Equipment Identify Team Makary M, Holzmueller C, Rowen L., et al. Operating Room Briefings. Joint Commission Journal Qual & Safety, 2006

Surgical Specimen Handling THE PROCESS Surgeon passes the specimen to the Scrub Nurse or Tech The specimen is then passed to the OR Circulator The Circulator obtains from the surgeon the name and laterality of the specimen

Surgical Specimen Handling A critical point of communication among OR providers Significant Implication for patient care Cancer diagnosis Laterality Measurable in a standardized fashion

Mislabeled Specimen Error Types No label No specimen Incorrect Laterality Incorrect Tissue Site Incorrect Patient No Patient Name No Tissue Site No Clinical History

The Goal: Measuring Quality

The Intervention A Verification Step to Check Specimen in the same way blood is checked before use Nurses read back the specimen name Surgeon to sign off after each case Mislabeled Specimens tracked at surgical pathology receiving desk

The Debriefing Verify the Specimen Were there any issues encountered? What could have been done to make the case more efficient? What could have been done to make the case safer? Signature _______________________

Conclusions Communication and Teamwork are associated with patient outcomes Mislabeled surgical specimens represent a measurable and preventable error in the surgical setting Surgical Specimen Labeling errors are a surrogate of poor communication in the OR A surgical specimen checklist, similar to checking blood products, can improve quality in the OR