What’s New in Safety in the OR?

1. What’s New in Safety in the OR? Keith P. Lewis, R.Ph., MD Professor and Chairman Department of Anesthesiology Boston University School of Medicine June 10, 2014 8:00-9:00 AM

2. Why Do Accidents Happen? Accidents appear to be the result of highly complex coincidences which could rarely be foreseen by the people involved. The unpredictability is caused by the large number of causes and by the spread of information over the participants...accidents do not occur because people gamble and lose, they occur because people do not believe that the accident that is about to occur is at all possible. Wagenaar and Groeneweg, Best Medicine

3. Lucian Leape, MD Everyone makes errors everyday No one makes an error on purpose An error is not misconduct We make errors for a reason

4. Why Do Errors Occur? Interruptions Fatigue Multi-tasking Failure to follow-up Poor hand-offs (hand-overs) Ineffective communication Workload fluctuations

5. Harvard Closed Claims Review Ten years of closed OB claims from Harvard hospitals 2-3 reviewers Structured review form Consensus required Most common team-related deficiencies Failure to cross-monitor: 76% Poor communication:67% 42% of cases could have been prevented or mitigated with better teamwork

6. Teamwork is a Solution It is the unidentified, uninterrupted error that may cause harm. Professionals trained in team behaviors are prepared to recognize, manage, and/or mitigate the impact of an unfolding error. - Team Performance Plus

7. Potential Crises Anaphylaxis Transfusion Reactions Malignant Hyperthermia Difficult Airway Fires Electrical Safety Cardiac Arrest But what do they have in common?

8. Recognition, Management, and Prevention of Specific Operating Room Catastrophes Presented at the American College of Surgeons 89th Annual Clinical Congress, Chicago, IL Christopher R. McHenry MD, Ramon Berguer MD, FACS, Rafael A. Ortega MD Journal of the American College of Surgeons Volume 198, Issue 5 , May 2004, Pages 810-821 It’s Everyone’s Business!

11. Features in Common Critical incidents Reason’s Swiss Cheese Relatively Rare Training (and re-training) Required Communication issues Fixation Errors Reportable events Litigation Prone

12. What is a “Critical Incident”? Term made famous by Cooper Defined: Occurrences that are “significant or pivotal, in causing undesirable consequences Also defined as: An event that led, or could have led to a problem Critical Incidents provide opportunity to learn about factors that can be remedied Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978 Dec;49(6):399-406.

13. t Reason’s Swiss Cheese Successive Layers of Defenses Unsafe Acts Precondition for Unsafe Acts Unsafe Supervision Organizational Influences Based on: Reason, J. (1990) Human Error. Cambridge: University Press, Cambridge

14. Aligned Holes Example: wrong site / wrong patient Failed or Absent Defenses Based on: Reason, J. (1990) Human Error. Cambridge: University Press, Cambridge

15. System Failure Based on: Reason, J. (1990) Human Error. Cambridge: University Press, Cambridge

16. Recommendations Analyze all critical incidents, including the ones that could have led to a problem Use a standardized approach to identify causes, system failures, and opportunities for improvement. Where was the “hole” in the Swiss cheese?

17. Cardiac Case “Eight thousand of heparin” vs. “A thousand of heparin” Communication Error

18. Communication Challenges Language barrier Distractions Physical space Personalities Workload Varying Communication Styles Conflict Lack of Verification of Information Shift Change/Handoffs

19. Communication is… The effective and accurate transfer of information from one provider to another More than simply speaking The responsibility of both the sender and receiver to ensure that the information has been transferred

20. “Communication is the response you get to a message you sent regardless of the intent” (anonymous) Words account for 7% of message* Tone of voice accounts for 38% Body language accounts for 55% *Mehrabian 1971

21. Stairway of Communication Done action Understood X X X X Not said Not done Not understood Heard Not heard Said Meant Closing the loop Modified from Miller’s Anesthesia. Elsevier 2009

22. Standards of Effective Communication Complete Brief Clear Avoid jargon (e.g. prohibited abbreviations) Timely Directed at an individual Verified

23. Communication Error Standard practice in the military, esp. in the Navy, is to use “voice procedure” to maximize clarity of spoken communication and reduce misunderstanding. Control Room aboard USS Seawolf submarine. (courtesy of www.navy.mil)

24. Recommendation • Use Closed-Loop Communication whenever possible.

25. “The Ether Screen”

26. Transparent Drapes Transparent Ether Screens: The Road to New Transparency Ortega R, Gonzalez M, Lewis K ASA Newsletter , February, 2010

27. The Missing Kidney In December 1954, Dr. Murray performed the world's first successful kidney transplant between the identical Herrick twins at the Peter Bent Brigham Hospital.

28. ETT Foreign Body Anesthesia Machine Ascaris ETT Kinking ETT Defective Severe Bronchospasm Chest Rigidity Turbinate Avulsion

29. Safety Trumps Efficiency

30. Is it OK to Proceed? match risk waste match Preparedness Complexity

31. Most Departments Preparedness Complexity

32. Preparedness Complexity Ideal Department

33. OK Model Card

34. Airway PREPAREDNESS Complexity Small chin Short neck Obese Goiter MP lV Normal MP l Small chin Short neck MP lll Small chin MP ll Preparedness

35. Recommendation Use an approach that prompts matching preparationwith the complexity of the challenge ahead.

36. Application of OK to Proceed Retained Foreign Body Wrong Site Surgery

37. Retained Foreign Body Axial CT of face showing foreign body in right TM joint region Agarwal et al., Otolaryngology 2013, 3:3

38. Retained Foreign Bodies Incidence: 1/8001 to 1/18,760 Final Instrument Count Often Correct Never Event Devastating for the patient: Infection, abscess, need for additional surgery

39. Assess COMPLEXITY Before Your Proceed • Know Risk Factors • Multiple Surgeons Present • BMI >40 • Rapid Closure/Changed Procedure • Procedure Done Different from Original Plan • Multiple Team Changes NEJM 2003;348:229-35

40. Add Levels of PREPAREDNESS Part of Universal Protocol Mandate X-ray for High Risk Procedures Manual/Visual Inspection of the Cavity Notification of Location on Field Retained Foreign Body Alert Train and Educate the Radiologist Avoid CUTTING pledgets

41. Wrong Site Surgery

42. Wrong Site Surgery • Incidence: 1/112,000 • Per year in a 300 bed hospital • Wrong-side arthroscopy: $450,000 Wrong cervical disc: $1,175,000 • Its PREVENTABLE • National Quality Forum – Never Event • Joint Commission – Sentinel Event Ann Surg 2007;246:395-405

43. Joint Commission’s Evaluation of 126 Cases Orthopedic 41% General Surgery 20% Maxillofacial, CV, 14% Oto, Ophthalmology Urology 11% All Others 14% Ambulatory (58%), Inpt OR (29%), ER/ICU (13%) Sentinel Event Alert 2001;Dec 5:24:1-3

44. Wrong Site Surgery in Otolaryngology-Head and Neck Surgery • Medline database 1980-2013 • 0.3%-4.5% of all wrong site surgery events • Wrong site surgery accounts for 5-6% of OTO medical errors • 9-21% of otolaryngologists report experience with WSS • Major issues: Inverted imaging and ambiguity on site marking • Temporary injuries with few cases of permanent disability or death • Future: Standardized protocol to confirm imaging accuracy and specialty or procedure specific checklist Liou T, et al. Laryngoscope, May 2013

45. What Are The System Breakdowns? Not verifying consent or site markings Surgeon specifying the wrong site Not completing a PROPER TIMEOUT Inaccurate consents/diagnostic reports/images Patient positioning (either concealing mark or promoting site confusion) Anesthesia interventions prior to Timeout

46. COMPLEXITY: What Are The Risk Factors? • Unusual physical characteristics/equipment set up • Multiple procedures/multiple surgeons • Surgeon characteristics (left-handed surgeons) • Time pressures • Permanency of marking • Lack of patient/family involvement

47. For PREPAREDNESS: Need A Standardized Approach Everyone marks the same way with same pen Always before induction of anesthesia Always use the preoperative checklist Always STOP FOR TIMEOUT Conducted by specific provider

48. For PREPAREDNESS: Need A Standardized Approach • Final Pause Occurs Before Incision (“Knife-Check”) • Repeat for multiple surgeons • Anyone can say Stop (TEAMS work) • Verification of discrepancies and resolution • Monitor compliance with protocol

49. The WHO Checklist • Divides the operation into 3 phases • Before induction (Sign In) • Before incision (Time Out) • Before leaving the OR (Sign Out) • Aim: “to reinforce accepted safety practices and foster better communication and teamwork between clinical disciplines…it is intended as a tool for use by clinicians interested in improving the safety of their operations and reducing unnecessary deaths and complications.”