Presentation on theme: "Surgical Specimen Errors in the Operating Room"— Presentation transcript:
1 Surgical Specimen Errors in the Operating Room Improving Quality of Care in Surgical CareSurgical Safety Program MCIC-Vermont
2 The Race to Improve Safety in U.S. Hospitals Why the hysteria?Institute of Medicine ReportU.S. Malpractice Crisis
3 Industries by Size, Productivity, and Efficiency Where We StandIndustries by Size, Productivity, and EfficiencyLowHotelsAirlinesTobaccoQuality (error rate)ComputersU.S. Postal ServiceAuto ManufacturingFood ServicesHealth ServicesHighLowHigh*Source: Advisory Board Company, 2005
5 Finding the Sweet Spot A Model for Improving Safety Central MandateScientifically SoundFeasibleLocal WisdomMakary MA, et al. Patient Safety in Surgery, Annals of Surgery, 2006
6 Attributes of System Level Measure for Safety Scientifically sound, feasible, important, usableApply to all patientsAligned with value; encourage desired behaviorsMeaningful to front-line staff who do the work
7 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.
8 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.
9 Safety and Communication The Hierarchy of the MedicineSafety and Communication
10 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
11 Familiarity with others is a critical component of effective teamwork Aviation Data74% of all commercial aviation accidents happen on the first day of a crew flying togetherReview of Major AccidentsNTSB 1994 Safety StudyLate or behind schedule: 55% (17-28%)First day of pairing: 73% (7-30%)First flight together: 44% (3-10%)Captain Flying: 81% (50%)
12 OR Briefing Checklist Time-Out Antibiotics DVT Prophylaxis Instruments and EquipmentIdentify TeamMakary M, Holzmueller C, Rowen L., et al. Operating Room Briefings. Joint Commission Journal Qual & Safety, 2006
13 Surgical Specimen Handling THE PROCESSSurgeon passes the specimen to the Scrub Nurse or TechThe specimen is then passed to the OR CirculatorThe Circulator obtains from the surgeon the name and laterality of the specimen
14 Surgical Specimen Handling A critical point of communication among OR providersSignificant Implication for patient careCancer diagnosisLateralityMeasurable in a standardized fashion
15 Mislabeled Specimen Error Types No labelNo specimenIncorrect LateralityIncorrect Tissue SiteIncorrect PatientNo Patient NameNo Tissue SiteNo Clinical History
17 The InterventionA Verification Step to Check Specimen in the same way blood is checked before useNurses read back the specimen nameSurgeon to sign off after each caseMislabeled Specimens tracked at surgical pathology receiving desk
18 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 _______________________
19 ConclusionsCommunication and Teamwork are associated with patient outcomesMislabeled surgical specimens represent a measurable and preventable error in the surgical settingSurgical Specimen Labeling errors are a surrogate of poor communication in the ORA surgical specimen checklist, similar to checking blood products, can improve quality in the OR
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