The number of wrong site surgeries reported as sentinel events to The Joint Commission continues to increase annually. However, the number reported to the Pennsylvania Patient Safety Authority reporting system has shown 3 consecutive quarters of improvement, perhaps aided by a regional collaborative that was very successful. But they note that one report of wrong-site surgery in a hospital that previously had no cases, highlighting the continuing need for vigilance and proper safety systems even in organizations with a good track record of safety.
The use of the surgical “timeout” and the use of the surgical checklist are key to avoiding not only wrong-site surgery but also avoiding other perioperative complications. However, compliance with these processes is often suboptimal. Two recent papers have addressed some of the challenges. The first paper (Vats et al 2010) looked at the barriers and challenges encountered in implementation of the WHO Safe Surgery Checklist (see our July 1, 2008 Patient Safety Tip of the Week “ ”) at their hospital. Like most hospitals, most nurses and anesthesiology staff were supportive of the checklist from the start but many surgeons were less enthusiastic. However, using local surgical champions helped win over those surgeons that were skeptical. They noted that the checklist process often took a long time at the beginning, primarily because lack of familiarity with the checklist required they read out each item in its entirety. With time, that became faster. For example, use of single word cues (eg. “antibiotics”) became useful. However, sometimes teams became so comfortable with the checklist that they began performing it by memory, sometimes omitting items. So teams were encouraged to use the paper checklist.
They did find some examples of “badly used checklist”. The WHO checklist has three parts. While the “sign-in” and “time-out” portions were usually completed, the “sign-out” portion (to be done before patient leaves the OR) was often not completed. Time pressures (when the surgeon or anesthesiologist felt that workflow was being delayed) would occasionally pressure nurses to cover items quickly. Dismissive replies (i.e. those replies that are affirmative but inaccurate) would often go unchallenged, a problem with hierarchy in the OR. And sometimes the checklist would be done when one of the key parties was absent.
Compliance with the checklist initially improved over time. However, when the research team ceased attending all operations, compliance fell. It improved when the research team again began attending all operations but fell again at the end of the research period, prompting another period of encouragement. The lesson here is that sustainability should not be accepted automatically. With passage of time there is likely to be a dropoff in compliance unless you have some system of vigilance or audit/feedback to keep it on track. In fact, regular audits are one of the factors they identified for successful implementation. The other “success factors” they identified were providing training and learning materials, good organizational and clinical leadership, cultivation of local champions, clarification of the role of each individual professional group, local measurement of effectiveness, and supporting local adaptation of the checklist as long as it does not become oversimplified.
The second recent paper (Johnston et al 2009) looked at compliance with the “timeout” and surgical site signing in orthopedics in Saskatoon, Saskatchewan (Canada). They actually reported two studies. The first looked at presence of the initials of the surgeon in the draped surgical field. The second study, done a year later after a surgical timeout process had been adopted, looked at both the presence of the surgeon’s initials and the completeness of the timeout in randomly selected cases. Their studies took place in several sites where the same surgeons practiced but the percentage of “emergenent” vs. “elective” cases differed. They found in the first study that the surgeon’s initials were visible in the draped field in 67% of the emeregent cases and 90% of the elective cases. In the second study, the surgeon’s initials were visible after draping in 61% of cases at the Trauma hospital (mostly emergent) vs. 83% at two “Elective” hospitals. Timeouts were conducted in 70% of cases before the incision, after the incision in 19%, and not done at all in 11%. Overall, both a timeout and surgeon’s initials were present in 70% and neither was accomplished in 7.4% of cases. The disparity in practices (by the same surgeons) between emergent and elective cases is striking and may provide some insight into why emergent surgery is one of the risk factors for wrong-site surgery.
Auditing compliance with your timeout and site identification procedures is not always easy. As the Vats group found, compliance was good when everyone knew they were being observed, then deteriorated afterward. So it is very difficult to audit compliance by sending an obvious “compliance observer” into the OR. The interesting thing about the Johnston study is that they utilized orthopedic residents as the (secret) observer and the cases were selected randomly. So using someone who is a frequent participant in the OR can be useful in the audit process. Otherwise, audio or video taping the timeout is probably the best method of auditing. We like the concept of videotaping entire cases because the videos are excellent tools in team training and process improvement. It is always interesting to hear an individual describe what he/she thought he/she said or did, then play back the video and see how what he/she said or did really came out in a different way!
The most difficult thing to audit during the timeout is the degree of attention of all the team members. We’ve done many columns on this site that have discussed the analogy between the surgical timeout and the aviation “sterile cockpit” concept, in which the undivided attention of all team members must be present during certain activities. We are often told that someone is not paying attention during the timeout and that responses are often perfunctory. Videotaping may facilitate identifying those sorts of responses.
For those who are interested, the audit tool used by the Johnston group is quite thorough and useful.
One of the lessons in the Vats paper is to allow modification of the WHO Safe Surgey checklist but don’t allow oversimplification. On the other hand, they also note that checklists that are too complicated are not good. We do have a tendency to add too many things to the checklists. But that is probably because too few OR teams make use of another very useful tool: the pre-op huddle or pre-op briefing. The latter are more informal get-togethers by all members of the surgical team before a case where needs and contingencies are raised. Some of the issues that might be discussed in a pre-op huddle are:
Our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare” discussed pre-op briefings. Lingard et al (Lingard 2008) used a checklist to structure short team briefings and documented both reduction in the number of communication failures and other utility of the intervention. Nundy and colleagues at Johns Hopkins (Nundy 2008) used a very simple format for pre-operative briefings that led to a 31% reduction in unexpected delays in the OR and a 19% reduction in communication breakdowns that lead to delays. The tool they used was simple and consisted of 5 key items:
But one of the unsaid messages in the Nundy paper is the KISS (“Keep It Simple, Stupid”) principle. Anticipate things and try to discuss the most serious things that might happen, but don’t make the process so complex and long that team members lose their attention. A typical pre-op huddle or briefing ordinarily takes no more than 3-4 minutes.
So take a look at your processes and see whether you have the right mix of items in your surgical timeout and your pre-op briefing. And make sure you also read the Pennsylvania Patient Safety Authority’s Principles for Reliable Performance of Correct-Site Surgery and their other great tools for preventing wrong-site surgery if you are not familiar with them.
The Joint Commission. Sentinel Event Trends Reported by Year.
Pennsylvania Patient Safety Authority. Pennsylvania Patient Safety Advisory. Improvement in Preventing Wrong-Site Surgery! Traction or Transient?
Pa Patient Saf Advis 2009 Sep;6(3):104-6.
Vats A, Vincent CA, Nagpal K et al. Practical challenges of introducing WHO surgical checklist: UK pilot experience. BMJ 2010;340:b5433
Johnston G, Ekert L, Pally E. J. Surgical site signing and "time out": issues of compliance or complacence. The Journal of Bone and Joint Surgery (American) 2009; 91: 2577-2580
supplementary material (checklist used in Study 2 of Johnston paper)
Henrickson SE, Wadhera RK, ElBardissi AW, Wiegmann DA, Sundt TM.
Nundy S, Mukherjee A, Sexton JB, Pronovost PJ, Andrew Knight A, Rowen LC, Duncan M, Syin D, Makary MA. Impact of Preoperative Briefings on Operating Room Delays: A Preliminary Report. Arch Surg 2008; 143(11):1068-1072
Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, Espin S, Bohnen J, Whyte S. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg, Jan 2008; 143: 12-17
Pennsylvania Patient Safety Authority. Principles for Reliable Performance of Correct-Site Surgery
Pennsylvania Patient Safety Authority. Tools for Preventing Wrong-Site Surgery.