In what way is your staff and facility most likely to get named in a lawsuit?
In what way is your staff and facility most likely to get named in a lawsuit?
A child comes in for repair of a cleft palate. The left side of the mouth already has been repaired, and this procedure is scheduled for the right side. The consent form is correct and is signed. The team performs a timeout, and everyone agrees they will work on the right side. The surgeon cuts into the left side, according to a media report.1
A resident notices the mistake. The surgeon stops and performs the surgery on the right side. The child recovers well and is discharged. However, this recent mistake was the Rhode Island hospital's fourth wrong-site surgery in recent years, the media report said. The state health department subsequently investigated. Preliminary findings indicate problems, including failure to follow hospital policies; inconsistent interpretation of the timeout policies; inadequate ongoing training about policy revisions; inadequate hospitalwide prospective assessment of the timeout policy as it applies to specific surgeries, such as oral surgery, multisite surgery, and vaginal surgery; and inadequate identification and reporting of near misses.2
The state health department just reached an agreement with the hospital for an examination and revision of its safety procedures. Part of that review includes an examination of which current policies don't work well. Surgery was suspended for at least two hours in each specialty so the review could be conducted. The hospital also will contract with a patient safety consultant to establish a system for reporting near misses. The hospital also will develop methods to regularly confirm that all members of the surgical staff understand policies and procedures. Finally, the hospital will clarify and standardize its timeout procedure.
Rhode Island isn't the only state cracking down on surgical mistakes such as wrong-site surgery. The Massachusetts Public Health Council recently decided to require aggressive public reporting of hospital errors. The new regulations also prohibit hospitals from charging patients for care required as a result of a hospital error. The Massachusetts action is just the latest in a growing movement to hold providers accountable for "never events." California recently fined two hospitals $25,000 each for leaving items inside patients and another one $25,000 for beginning to perform a procedure on the wrong patient after a nurse failed to check a patient identification.3
"The quickest way to get sued is to perform the wrong surgery on the wrong person, or operate on the wrong organ," says Robert W. Markette Jr., CHC, JD, partner with Gilliland & Markette in Indianapolis. Such cases also receive the most publicity, he adds.
Wrong-site surgery is the No. 1 reported sentinel event to The Joint Commission. The number of such surgeries has increased from fewer than 20 in 1998 to 116 in 2008. Consider these suggestions to avoid the most common liability areas in outpatient surgery:
• Use a checklist.
The American Association of Orthopaedic Surgeons (AAOS) says checklists can be used prior to surgery to ensure that consent forms are completed and signed, the history and physical (H&P) is accurate, the test results are correct, and all equipment is available and correct for the patient.
A checklist with correct counts for equipment and supplies can help ensure you don't leave any items inside a patient, Markette says. Safety experts point out that pre-flight checklists have dramatically reduced pilot or mechanical diseases in military and commercial aviation. He points to cases in which sponges or medical equipment have later been found inside a patient. "If you had done a checklist, you'd say, 'The totals don't match up,'" Markette says. "You'd better find it. If you don't, when another doctor finds it, you'll get called by a malpractice attorney."
• Select the right patients.
Two years of outpatient surgery claims recently were reviewed by Waldene K. Drake, RN, MBA, vice president of risk management and patient safety at Cooperative of American Physicians — Mutual Protection Trust (CAP-MPT) in Los Angeles. "First, I see a lot of poor patient selection," she says.
For example, about 30% of the claims involved plastic surgery, Drake says. "These patients may be having cosmetic surgery for the 'nth' time and may never be satisfied with the outcomes," she says. "That is a definite red flag."
Another problem is patients who are too ill to be having procedures in a freestanding center, Drake says. "They, or their surgeon, may want the convenience it offers, or the patient may be paying cash and the charges are less," she says. "The surgeon must evaluate the appropriateness of the surgical setting based on the entirety of the patient's health history and needs."
• Be prepared and alert for complications.
Being able to recognize a complication early, and being prepared for an emergency are critical, Drake says. "Because sicker patients are coming to centers, and because bigger procedures are being done on an outpatient basis, I expect more patients to have complications," she says. "Staff have to be 'on their toes' for early recognition of breathing difficulties, changing vital signs, changing levels of consciousness."
Conduct practice sessions on what to do in an emergency, and be certain that emergency equipment is in good condition, Drake suggests. Having an arrangement to admit patients to a local hospital for complications also is good preparedness, she says. "In the claims, I see complications like strokes, bleeding, etc., postoperatively, sometimes in the center, and sometimes they aren't recognized until the patient is home," Drake adds.
• Document.
If anything goes wrong in a case, whether it is preventable or not, you'll be second guessed as to whether you followed the standard of care, Markette warns. "Like being a sportscaster on Monday morning, it's easy to say you should have gone for it on third and 1," he says.
If you find errors in the documentation, there are proper ways to correct it, such as placing a line through the original documentation and initialing it, Markette says. "But if there is a chance of a malpractice case later, and there is an error correction, I get skittish," he says. "Ask, why are you correcting records after the fact?"
References
- Freyer FJ. R.I. Hospital to examine its surgical safety issues. The Providence Journal, May 16, 2009. Accessed at www.projo.com/health.
- Rhode Island Government. HEALTH Signs Consent Agreement with Rhode Island Hospital Regarding their Wrong-Sided Surgery. Accessed at www.ri.gov/press/view/8903.
- Lin II R, Yoshino K. Southern California hospitals fined for violations. May 21, 2009. Accessed at www.latimes.com/features.
Guidelines can prevent wrong-site surgery In a recent case in Connecticut, a patient had herniation on the left side of the spine, says Robert W. Markette Jr., CHC, JD, partner with Gilliland & Markette in Indianapolis. The medical record said the problem was on the left side, but the surgeon went into the preoperative area and told the nurse the problem was on the right side. He proceeded to perform surgery on the right side. According to the American Association of Orthopaedic Surgeons (AAOS), wrong-site spinal surgery can be prevented by an intraoperative X-ray that marks the exact site of surgery. Other steps to avoid wrong-site surgery include following The Joint Commission's Universal Protocol. According to the most recent statistics from The Joint Commission, 20% of hospitals were cited in the first half of 2008 for not complying with the timeout requirement in the Universal Protocol. A proper timeout includes confirmation of the patient's identity, procedure, site, equipment and devices, and antibiotics to administer, according to AAOS. All members of the surgical team should participate in the timeout, the association says. Some providers believe the timeout should be expanded to a briefing. AAOS advises the surgeon, in consultation with the patient, to place his or her initials on the operative site with a permanent marking pen. "Put your initials on the knee pre-surgery, and you avoid that kind" of problem with wrong-site surgery, Markette suggests. "Those kinds of mistakes shouldn't happen," he adds. |
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