SafetyDog

Wrong side wrong system?

In BEST.ARTICLE.EVER., Checklists, Force function, Human Factors on May 9, 2013 at 7:28 am

Another article about a recent wrong side surgery: http://www.stltoday.com/business/local/ssm-health-care-apologizes-for-brain-surgery-error/article_05e1c0fa-fd7c-5aa0-a30f-1784edfd7d39.html

SSM Health Care acknowledged Tuesday that its neurosurgeon and medical staff recently operated on the wrong side of a St. Louis-area woman’s brain and skull.
The admission — and a lengthy public apology — followed a Post-Dispatch story in Tuesday’s paper about a lawsuit filed Friday on behalf of Regina Turner of St. Ann.
“SSM Health Care and SSM St. Clare Health Center sincerely apologize for the wrong-site surgery in our operating room,” Chris Howard, president and chief executive of SSM Health Care-St. Louis, said in a written statement. As a result of the mistaken surgery on April 4, Turner, 53, now needs 24-hour nursing care for her basic needs and cannot speak intelligibly, said Alvin Wolff Jr., her Clayton-based attorney.
According to the lawsuit filed in circuit court in Clayton, the former paralegal “will also continue to suffer from emotional distress, anxiety, disfigurement and depression.”

“This was a breakdown in our procedures, and it absolutely should not have happened,” Howard wrote in his statement. “We apologized to the patient and continue to work with the patient and family to resolve this issue with fairness and compassion. We immediately began an investigation.”

Time outs and checklists have reduced the incident of wrong side surgery but not eliminated the problem. Let’s analyze this from the human factors/risk management Hierarchy of Intervention Effectiveness (see graphic below). Capture
While checklists and standard time-outs are better than education, they do not reach the level of automation or force function.

In the words of Cafazzo & St-Cyr (2012,http://www.longwoods.com/content/22845)
“Although checklist use has recently made headlines in its ability to reduce adverse events in settings such as the operating room and intensive care (Haynes et al. 2009; Pronovost 2006), it remains unclear that an intervention so fundamentally reliant on human behaviour will be sustainable in the long term without constant enforcement (Bosk et al. 2009). Are all healthcare organizations able to create a culture for the sustained use of checklists? If this solution applies only to organizations that have the leadership and resources to maintain such a culture, checklists – and other solutions reliant on human behaviour – cannot be considered a systemic solution. Given how rare serious adverse events are to the total volume of healthcare encounters, a solution that applies to only a fraction of organizations cannot address this safety issue fully.”

My thoughts: why can’t we ace wrap the WRONG side…with a distinctive sterile wrap designed like yellow police tape (DO NOT CROSS!).. it can be removed once the first cut is made into the appropriate surgical site.
Simple, but it would provide some force function as the team would literally have to remove a wrapping that said “WRONG SIDE” in order to make a mistake!

Graphic: Cafazzo and St-Cyr, 2012
http://www.longwoods.com/content/22845
A safetydog: BEST.ARTICLE.EVER.

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