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

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Presentation on theme: "Surgical Specimen Errors in the Operating Room Improving Quality of Care in Surgical Care Surgical Safety Program MCIC-Vermont."— Presentation transcript:

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

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

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

4 How do we know we are safer?

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

6 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

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.

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9 The Hierarchy of the Medicine Safety 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 Data 74% of all commercial aviation accidents happen on the first day of a crew flying together

12 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

13 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

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

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

16 The Goal: Measuring Quality

17 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

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 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


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