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Surgical Specimen Errors in the Operating Room

Surgical Specimen Errors in the Operating Room. Improving Quality of Care in Surgical Care. Surgical Safety Program MCIC-Vermont. Institute of Medicine Report. U.S. Malpractice Crisis. The Race to Improve Safety in U.S. Hospitals. Why the hysteria?. Where We Stand.

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Surgical Specimen Errors in the Operating Room

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

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

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

  4. How do we know we are safer?

  5. Finding the Sweet SpotA 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. Sentinel Events : Evaluating Cause and Planning Improvement. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 1998.

  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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