8 Steps to "Chase Zero" With Wrong-Site Surgery
1. Start from the top. If OR team members are going to take wrong-site/side surgery seriously, the message needs to start in the C-suite, Ms. Groah says. "There has to be a concept at the very top that patient safety is number one at the institution," she says. This means the topic should be discussed in whatever method the CEO uses to communicate with the whole hospital — town-hall meetings, regular emails, video chats, etc. "If the CEO really believes and puts forward the message of preventing wrong-site surgery as part of their strategy, everyone else will understand the importance of it," she says.
2. Involve all the stakeholders. Ms. Groah says there are three main groups of providers who actually touch the patient: nurses, surgeons and anesthesiologists. All three groups have to agree on the format for double-checking the correct side and site of surgery. Ms. Groah says most surgical facilities use a version of the World Health Organization, Joint Commission or CMS recommendations around using a surgical checklist.
She says the lists are often modified to fit hospital needs; for example, a pediatric hospital would need to add special precautions for young patients, while hospitals with extensive use of laser and electrosurgery machines might add checklist issues about fire protection. Ms. Groah says the process of customizing the surgical checklist for a facility should involve the OR director, the head of nursing, the chief of surgery and the chief of anesthesia.
3. Educate all OR members together. Ms. Groah recommends holding an education session about wrong site/side surgery that includes all OR team members. One of the biggest roadblocks to successful prevention of wrong site/side surgery is a lack of collaboration in the OR, she says. In many cases, the surgeon will go ahead with the case without stopping to check the side and site of surgery, and other providers do not feel comfortable interrupting the process.
She says every member of the OR — the surgeons, anesthesia providers and nurses — should sit down together and discuss the benefits of the checklist. She recommends providing literature on the effectiveness of using a surgical checklist, as well as going through role-playing exercises to get providers used to checking in with each other. She says some hospitals have taken extra measures to make sure the surgical checklist is visible. For example, some facilities color-code their checklists to show which staff members are responsible for which tasks. Other facilities post the checklist on an electronic board on the wall of the OR, so that everyone can see each step as it is completed.
4. Ask the surgeon to take the lead. Ms. Groah says the surgeon should start the checklist process by getting the attention of all OR members and saying, "Let's go through the checklist." All the OR team members should then introduce themselves to encourage collaboration and show who's responsible for the care of the patient.
Once everyone has been introduced, the circulating nurse should go down the checklist and complete every precautionary task, including double-checking the side and site of surgery. Every person in the OR should have their complete attention focused on the checklist, to make sure no miscommunications occur.
6. Institute a number of "double checks" to ensure the right side/site is understood. Prior to surgery, the facility should institute a series of "double checks" to make sure everyone is on the same page about the side and site of surgery. "It starts in the surgeon's office, when the patient and the surgeon agree to surgery," Ms Groah says. "At that point in time, they'll say, 'We're going to operate on your left hip,' and that's the way the procedure is scheduled when the surgeon fills out a form or calls the scheduling office."
She says the patient will then sign a consent form prior to surgery, which can occur either during the office visit or during a pre-op visit within two weeks before surgery. The consent form should clearly say where the surgery will occur on the patient. The surgeon would then make a note in the chart before surgery and mark the side and site on the patient in the pre-op area, so the patient can participate. The circulating nurse would check the consent form and the OR schedule when she checks the patient in prior to taking the patient to the OR.
7. Install "secret shoppers" to check up on OR compliance. Once you have educated your OR team members about the surgical checklist process, you need to know if they're complying with the policy. Ms. Groah says the best way to do this is to assign a "secret shopper" to make rounds and observe team members on a regular basis.
"Nobody knows the person is observing the protocol for the checklist," Ms. Groah says. "The advantage to the concept is that if you're being watched, you're going to do it the right way." If team members don't know they're being watched, they'll give a more accurate portrayal of what happens in the OR on a daily basis.
8. Debrief after surgery to go over "near misses" and "good catches." Ms. Groah says it's important to reserve some time after surgery to review everything that happened. In the debriefing, people have the opportunity to talk about instances when a wrong site/side surgery or other untoward events could have happened, but didn't. This provides a learning opportunity for the next surgery, because "near misses" will probably be avoided in the future if the staff members understand why they happened.
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