Study says wrong-patient procedures underreported: JCAHO gets involved
Agency requires compliance with new patient safety goals by Jan. 1
What do the Challenger space shuttle disaster, Chernobyl nuclear reactor explosion, and the Bhopal chemical factory catastrophe have in common with invasive procedures performed on the wrong patients? They all involve many individuals converging and interacting with system weaknesses, increasing the likelihood that individual errors will do harm, according to a recent study reported in the Annals of Internal Medicine.1 When you throw short stays and growing caseloads of outpatient surgery patients into the mix, the likelihood of errors doing harm increases, some surgery experts say.
Wrong-patient medical errors are underreported, according to the report. And the problem isn’t limited to large organizations such as hospitals, says Richard Croteau, MD, executive director of strategic initiatives at the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL. "A patient who comes in for a procedure interacts with large number of people and systems within an organization, even in a small freestanding surgery center," Croteau says. "There’s still a lot of interaction, and lot of opportunity for checks, but there are also lots of opportunities for breakdown in communication."
Anyone from the admitting clerk to the patient can be responsible for wrong-site or wrong-patient surgery, says Tom Russell, MD, executive director of the American College of Surgeons in Chicago. Russell recalls one case in which a hospital employee shaved the wrong side of the patient. "That set up a sequence of events that led to wrong-sided surgery," he says. "Ultimately, the surgeon carries on a procedure on the wrong patient, or on the wrong side. There’s a chain of events here. That’s why it is a system problem."
Carol Beeler, past president of the Alexandria, VA-based Federated Ambulatory Surgery Association, says, "While we believe the ambulatory surgery center industry provides high-quality care, even one wrong-site surgery occurring is one too many. The Federated Ambulatory Surgery Association’s goal is that not a single wrong-site surgery occur in our industry, and we will continue our efforts to make that a reality."
The Joint Commission has announced six patient safety goals, with 11 corresponding recommendations, that accredited facilities must meet by Jan. 1, 2003. Of the six announced, one addresses wrong-patient surgery, and another addresses patient identification, which often is cited as a factor in wrong-patient surgery. The goals will be surveyed in all regular and unannounced surveys, and organizations must meet all 11 recommendations or risk a Type 1 recommendation. New national patient safety goals will be issued each year. The patient safety goals were based on the sentinel events that have been tracked since 1995. The Joint Commission has reported 20 incidents on wrong-patient surgery. They resulted in one death, and six patients suffered major permanent loss of function.2
In comparison, New York state, which maintains its own mandatory error-reporting system, reports 27 incorrect patient/invasive procedures from April 1998 through December 2001.3 Eight were surgical procedures. None resulted in death or permanent loss of function. This disparity is one reason that experts suggest the voluntary Joint Commission database isn’t complete.
The old system of checks and balances doesn’t operate in a system in which patients come in, are processed and operated on, and go home the same day, Russell emphasizes. The current outpatient surgery system is being strained, he says.
"Having been a practitioner for many years myself, I can tell you it’s quite a frenetic pace now," Russell says.
While there are no data on changes in the rates of wrong-patient surgery, "any circumstances that make it more likely that doctors and nurses will be relatively unfamiliar with their patients — and therefore less likely to recognize when plans are deviating from a course that makes sense for a particular patient’s condition — are likely to contribute to the problem," says Elise C. Becher, MD, MA, assistant professor of pediatrics and health policy at Mount Sinai School of Medicine in New York City. Becher is one of the authors of the Annals study. These factors aren’t likely to be fixed soon, she says. "That is why it is important to focus on improving systems of communication, teamwork, and patient identity verification, where we can make changes and have a real impact."
Consider these specific areas for improvement:
• Informed consent. Informed consent is not a piece of paper to be signed, Croteau emphasizes. "It’s a process that’s involved communicating with the patient," he says.
Becher concurs that patients should be partners in the decision-making process. Obtaining the signature on the consent form should not be merely a "rubber stamp, but rather the final step in a truly collaborative endeavor," she says. Informed consent should not be done immediately prior to the procedure, Becher contends.
You can’t do an adequate job of informed consent without spending time with the patient, Russell adds. He says the process should be handled in the surgeon’s office, where the surgeon can talk to the patients, offer educational material, and even suggest they talk to other patients. "You can’t do it in 10 seconds, or a minute," Russell says. "You have to explain, re-explain, give reading materials, and maybe have another session."
• Patient identification. There should be routine, standardized procedures for verifying patient identify, and managers must ensure that the procedures are adhered to, the Annals authors say. Conduct audits periodically to ensure this is happening, they suggest. "Add birth dates or medical record numbers to patients’ names in the scheduling system. Have a strict protocol on all units to ensure that only correctly identified patients with written orders in their charts are permitted to leave their floors for procedures." Engage the patient in identification, or engage the parent if you’re operating on a child, Croteau suggests.
Donald J. Palmisano, MD, JD, a surgeon from New Orleans and a member of the Board of Commissioners for the Joint Commission, said he always visits the patient before the procedure. "I do it for two reasons: I want to make sure it’s my patient, and second, I want the patient to have the comfort of knowing that I am there before [going] to sleep," he said.4
Use a verification checklist to ensure you have all of the documentation, that the documents are consistent with each other and for that patient, and that they all include the same procedure and site, Croteau advises.
• Communication and teamwork. Wrong-patient surgery can occur when there are last-minute changes to room assignments in the OR or changes in scheduling, he says. Recently, one surgeon had three patients scheduled, and the second one was canceled by anesthesia. "The surgeon went in expecting to do the second case, but the third case was moved up," Croteau says. He was operating on the third patient, but was performing the second procedure, he says.
Wrong-patient surgery almost always has a breakdown in communication among the staff, Croteau says. "In that particular example, there was a breakdown in communication between anesthesia staff and the surgeon." Before starting the operation, just before the incision is made, pause briefly to check with everyone involved in that operation and acknowledge aloud the patient, the procedure, and the site, he advises.
The problems hindering effective communication among staffs must be addressed, experts say. "One place to start is to have clinical leaders [physicians and nurses] openly discuss problems of poor communication and teamwork with staff on a regular basis," Becher says. "Regular workshops or case presentations can facilitate such discussions," she adds.
• Full and immediate disclosure when an event happens. Wrong-patient surgery absolutely should be frankly discussed with the patient and family, with no effort to cover it up, Russell advises. Report such events to the Joint Commission. Always conduct a root-cause analysis to discover the cause, he suggests. "You must change the system to prevent it happening again," Russell says.
References
1. Chassin MR, Becher, EC. Ann Int Med 2002; 136: 826-833.
2. Forstneger M. Personal communication, July 31, 2002.
3. Heigel F. Personal communication, Feb. 14, 2002.
4. Joint Commission on Accreditation of Healthcare Organizations. Teleconference Transcripts: Wrong Site Surgery and Sentinel Event Alert 24 — A Follow-Up Review of Wrong Site Surgery. Dec. 5, 2001. Accessed at www.jcaho.org.
Sources
For more information on wrong-patient surgery, contact:
• Elise C. Becher, MD, MA, Assistant Professor of Pediatrics and Health Policy, Mount Sinai School of Medicine, New York, NY. E-mail: [email protected].
• Richard Croteau, MD, Executive Director of Strategic Initiatives, Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL. E-mail: [email protected].
• Tom Russell, MD, Executive Director, American College of Surgeons, 633 N. Saint Clair, Chicago, IL 60611-3211. Telephone: (312) 202-5305. Fax: (312) 202-5316.
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