Patient Safety Tip of the Week
October 30, 2012
Surgical Scheduling Errors
Last week we
discussed latent factors in the OR and other things that can go wrong in the OR
itself (see our October 23, 2012 Patient Safety Tip of the Week “Latent
Factors Lurking in the OR”. This week we are going to discuss some of the
issues that occur well before the patient goes to the OR that may have an
impact on patient safety, patient outcomes, and even hospital finances. And in
a future column we’ll deal with issues related to postoperative care.
Our August 2011
What’s New in the Patient Safety World column “New
Wrong-Site Surgery Resources” highlighted the Joint Commission Center for Transforming Healthcare’s Wrong
Site Surgery Project. This was a collaborative done in conjunction with 8
healthcare systems. They basically identified many of the key factors
contributing to cases of wrong-site or wrong-patient surgery, then planned and
tested interventions aimed at eliminating or mitigating those factors. They
found important factors in scheduling, the pre-op/holding area, the OR itself,
and organizational factors that were important contributors to wrong-site
surgery. The “fact
sheet” they provide lists the contributing factors in each domain along
with identified solutions and the “storyboards”
walk you through the steps they used in each domain, identifying “defective
cases” and measuring the improvement over time in the rates of defective cases.
One of the areas quite vulnerable
to contributing to wrong site surgery was the surgical booking and scheduling process. Some of the booking and scheduling issues
predisposing to wrong site surgery (their list plus some of our own) are:
- Verbal requests accepted without written documents
- Booking documents not verified by office schedulers
- Miscommunications between surgeons and their own office staff
- Scheduling delegated to staff unaware of nuances of scheduling
- Nonclinical people on either end not understanding clinical issues
- Unapproved abbreviations, cross-outs, and illegible handwriting used
on booking forms
- Faxed booking documents with artifacts
- Missing consent, history and physical, or surgeon’s orders at time
of booking
- Use of secondhand information rather than primary document
verification
- Booking multiple cases simultaneously
- Last minute scheduling changes
- Computer systems not able to talk to each other
- Procedures added on to the primary procedure
- Thinking a case is scheduled when it is not
In a study looking at factors
related to wrong site surgery Clarke et al. found the most commonly implicated
factor reported to the development of wrong-site errors was scheduling of the
procedure with the OR but it was implicated in only a minority of events that
actually touched the patient (Clarke
2007).
A new study (Wu
2012) did a qualitative and quantitative analysis of errors occurring
during the surgical booking/scheduling process and identified not only patient
safety issues but also analyzed the costs associated with the delays such
errors end up causing. Looking at over 17,000 surgeries they found a booking
error rate of 0.86%. Of the booking errors wrong side was listed on 36%.
Another 25% were incomplete and may not have included the laterality. Wrong
approach (eg. laparoscopic rather than open) accounted for 17% of the errors.
Other booking errors included wrong patient information, wrong procedure, wrong
site, and even wrong patient.
The type of booking
error was influenced by the nature of the surgical specialty. For example, most
wrong approach errors were in general surgery but laterality errors were more
common in plastic surgery, orthopedic, ophthalmologic, and ENT procedures.
Most of the errors were caught in
the holding area or the OR but some were caught in the admission/registration
area or assessment areas. The errors were discovered about equally between the
first case of the day, the rest of the morning, and afternoon. We’ll see later
that the time of catching the error also impacts on the costs associated with
that error.
They did focus groups with OR nurses
and technicians to address the impact of such errors and identify potential
solutions. Such scheduling errors create additional paperwork and lead to time
pressures, hurriedness, and delays. The time delays depended on the type of
surgery. For example, a wrong approach booking error in general surgery might
take 15-30 minutes to correct and even longer if the case is in the afternoon
when other ongoing cases might create staffing and equipment issues. On the
other hand, ophthalmology booking errors might take seconds to 15 minutes to
correct.
On average, the delay was about
20 minutes. They calculated that at OR costs of $16 per minute the average cost
per delay was $320. That does not include potential costs for overtime (if the
case was late in the afternoon) or costs for extra equipment (if two separate
surgical setups were required). So the costs of these errors can add up
considerably. This is another reason you want to bring your CFO to your quality
meetings and patient safety rounds!
Hospitals can start by limiting
the number of sites or persons that can do surgical bookings and then use
checklists or other tools for verification that all appropriate materials have
been received and are accurate.
Your surgical booking process
should require specific items be filled in and specific documents received
before giving that case a final time slot. For example, you should require a
copy of the informed consent and the history and physical before booking so
that you can match the information on those against the scheduled procedure.
Note that having a copy of the history and physical will also allow you to
identify cases in which the H&P will “expire” before the 30-day Joint
Commission requirement. You should also include pre-op orders where appropriate
(eg. for prophylactic antibiotics).
The Wu paper notes that the
Minnesota Alliance for Patient Safety created a sample
booking form that contains a section
which must be filled out by the physician performing the surgery (i.e. that
cannot be delegated to staff). The Minnesota Alliance for Patient Safety has
several other valuable resources as part of its Surgery
Scheduling and Verification Pilot Project. These include algorithms for
scheduling for either the hospital or ambulatory surgery center and for the
clinic or physician office, and verification checklists for both sites. The
Pennsylvania Patient Safety Authority also has a sample
OR scheduling form as part of its extensive resources on preventing wrong
site surgery plus a checklist
for the surgeon’s office.
Your booking form should also
have an area any needed special equipment or implants can be recorded. We also
recommend you have an area that indicates whether a surgical specimen (for
pathology) is anticipated.
Abbreviations on booking logs and
forms can be problematic and should not be used. Ophthalmologists like to use
OD/OS for right eye and left eye in their notes. They should spell out right
eye and left eye. We’ve seen cases where “OD” gets misinterpreted as “AD” and
antibiotic drops get put in the right ear instead of the right eye. Similarly,
some of us like to indicate right or left or bilateral by using circles around
an “R”, “L”, or “B” respectively. That is particularly dangerous in scheduling
since it is very easy to mistake these for the wrong side. Note that fax
artifacts can further lead to misinterpretation of some abbreviations (see our
June 19, 2012 Patient Safety Tip of the Week “More
Problems with Faxed Orders” for a discussion on types of errors related to
faxes and how to avoid them). So you really shouldn’t use abbreviations at all
on your booking forms. Similarly, you should not use acronyms on your
scheduling forms since all parties may not understand those.
Surgical procedure codes may not
match the description of the procedure being scheduled. For those who enter a
procedure code on the scheduling form we always recommend a written description
also be included so that staff can cross check to make sure what the intended
procedure is and reconcile any discrepancies.
If more than one procedure is
being scheduled on the patient, be sure that the consent form includes all the
procedures (and that the other information for that subsequent procedure is
also included if relevant).
Availability of imaging studies
is another important facet to be considered during scheduling. Some hospitals
or ASC’s include a checkbox on their booking form for the need for images to be
present in the OR and clarify who is responsible for being sure those images
are present. The same applies to copies of office notes. Having copies of
office notes available may become critical when a discrepancy is noted when the
patient is in the pre-op area or OR.
In one of their earliest studies
on wrong site surgery the Pennsylvania Patient Safety Authority noted that
discrepancies in information obtained from the surgeon’s office was common in
both near-misses and actual wrong site cases (PPSA
2007).
The sample verification
checklists available at the Minnesota Alliance for Patient Safety website for
its Surgery
Scheduling and Verification Pilot Project are tools you should be using at
your hospital/ASC and your physician offices, respectively.
The Clarke study pointed out that
the patient, family, and preoperative nurse were the most important protections
against wrong site surgery. They noted that nurses doing verification and
reconciliation in the preoperative holding area were most effective in catching
errors before they might reach the patient. But they also point out important
roles for the surgeon and anesthesiologist. We’ve emphasized over and over the
importance of the pre-op huddle.
That is the brief meeting of the surgeon, anesthesiologist, and OR nurse that
should occur before every case before the patient is taken into the OR itself. That
is where many of the wrong site/wrong patient/wrong procedure errors can be
identified and where missing equipment or missing implant issues can be
identified. We recommend you develop checklists to guide those pre-op huddles
and the checklists can be tailored for the specific type of surgery being done
(i.e. the needs for an ob/gyn surgery pre-op huddle will differ considerably
from an orthopedic one).
The Wu study also identified 3
other potential areas/times where booking errors might be identified before the
pre-op huddle or OR timeout. These include when the patient first arrives and
checks in, when the patient is admitted and has an identification bracelet put
on, and when the nursing assessment is being done.
Some scheduling errors may occur
outside the traditional surgical booking process. Add-on cases and last minute
scheduling changes can also be problematic. Where verbal requests are being
accepted (as above, we don’t recommend you accept such verbal requests but
sometimes in emergent situations you have no choice) “hearback” and “readback”
should be utilized just as you would taking a verbal order via telephone. Day
of surgery changes in the order of cases is also a practice that may lead to
errors. Cases where the schedule is changed to accommodate an angry patient who
thought he was going to be the first case of the day have been known to result
in wrong patient procedures.
Because wrong site surgery
remains a relatively rare occurrence it is, of course, difficult to monitor the
success of your interventions to prevent it. However, as in the Joint
Commission collaborative, you can audit the error rates in the individual
processes that may contribute to wrong site surgery. So formally auditing your
surgical scheduling processes and identifying errors is a good practice.
Some of our prior columns
related to wrong-site surgery:
Patient Safety Tip of the Week
columns:
September 23, 2008 “Checklists
and Wrong Site Surgery”
June 5, 2007 “ Patient
Safety in Ambulatoy Surgery”
March 11, 2008 “Lessons
from Ophthalmology”
September 14, 2010 “Wrong-Site
Craniotomy: Lessons Learned”
November 25, 2008 “Wrong-Site
Neurosurgery”
January 19, 2010 “Timeouts
and Safe Surgery”
June 8, 2010 “Surgical
Safety Checklist for Cataract Surgery”
December 6, 2010 “More
Tips to Prevent Wrong-Site Surgery”
June 6, 2011 “Timeouts
Outside the OR”
What’s New in the Patient Safety World columns:
July 2007 “Pennsylvania
PSA: Preventing Wrong-Site Surgery”
August 2011 “New
Wrong-Site Surgery Resources”
References:
Joint Commission Center for Transforming
Healthcare. Wrong Site Surgery Project.
http://www.centerfortransforminghealthcare.org/projects/display.aspx?projectid=4
fact sheet
http://www.centerfortransforminghealthcare.org/UserFiles/file/CTH_Wrong_Site_Surgery_Project_6_24_11.pdf
storyboards
http://www.centerfortransforminghealthcare.org/UserFiles/file/CTH_WSS_Storyboard_final_2011.pdf
Clarke JR, Johnston J, Finley ED.
Getting surgery right. Ann Surg 2007; 246(3): 395-405
http://journals.lww.com/annalsofsurgery/Abstract/2007/09000/Getting_Surgery_Right.6.aspx
Wu RL, Aufses AH.
Characteristics and costs of surgical scheduling errors. Am J Surg 2012; 204(4): 468-473, October 2012
http://www.americanjournalofsurgery.com/article/S0002-9610%2812%2900191-2/abstract
Minnesota Alliance for Patient
Safety. Surgery Scheduling and Verification Pilot Project.
http://www.mnpatientsafety.org/OurWork/PastWork/SurgerySchedulingandVerificationProject.aspx
The Pennsylvania Patient Safety
Authority. Wrong Site Surgery tools.
sample OR scheduling form http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/PWSS/Documents/orschedule.pdf
checklist for the
surgeon’s office
http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/PWSS/Documents/office_tip.pdf
PPSA (Pennsylvania Patient Safety
Authority). Insight into Preventing Wrong-Site Surgery. PA PSRS Patient Saf
Advis 2007; 4(4): 109, 112-23
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2007/dec4%284%29/Pages/109b.aspx
Print PDF
version

http://www.patientsafetysolutions.com/
Home
Tip of the
Week Archive
What’s New in the
Patient Safety World Archive