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. 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

4. How do we know we are safer?

5. 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

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.

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 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
Review of Major Accidents
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%)

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