ECSforResidentsTIMEOUTS presentation.pptx

it describes the needs for time outs process inside and outside OR

1. Patient Safety for Residents Module 1 ‘Time Outs’ You may view this PowerPoint presentation as a Slide Show and listen to the optional audio narration of the Notes (turn speaker volume up/down). Use your keyboard “Enter” or "Page Up/Down" keys to advance the slides manually. Alternatively, you may view the presentation without audio in the Slide or Outline tab. In these modes, printed Notes will be available beneath the slide content. Please advance to the next slide to begin.

2. Patient Safety for Residents Module 1 ‘Time Outs’ Use “Enter” or “Page Down” key to advance to Next Slide

3. Veterans Administration Quality Improvement Program (VASQIP) Formerly National Surgical Quality Improvement Program (NSQIP) Origins of VASQIP Public Law 99-166, 1986- Congress mandates the VA to report surgical outcomes in comparison to national average with risk adjustment for patient illnesses What Does VASQIP Involve? Facilities review outcome reports on a quarterly basis - monitoring performance Site visits for structure and processes of care assessment and recommendations for improvement Dissemination of best practices Implementation of safety programs such as prevention of wrong site surgery Itani , K. (2009). Fifteen years of the National Surgical Quality Improvement Program in review. Amer J Surg 198 (Supplement), S9-S18. Next Slide

4. Course Objectives Discuss incorrect surgery and invasive procedures in healthcare. Review The Joint Commission Universal Protocol , VHA Directive 1039 Ensuring Correct Surgery and Invasive Procedures , and time outs. Demonstrate Crew Resource Management communication techniques that aid in ensuring correct surgery (ECS) and invasive procedures. Practice the steps to ECS in a virtual patient simulation scenario. Next Slide

5. Module I. ‘Time Out’ Briefings Incorrect surgery & procedures likely occurred throughout history. Examination of ancient skulls with multiple trephination holes serve as possible evidence. Next Slide

6. Definition of Incorrect Surgery & Invasive Procedure Any procedure that has been performed on the opposite side, incorrect site, or incorrect level of the body; is performed on the wrong patient; or is the wrong procedure; or uses the wrong implant. Next Slide

7. Incidence of Incorrect Procedure 1 in 51,540 to 1 in 112,994 operations 5 to 10 events daily in the United States One event or close call every other day in state of Pennsylvania 100 events in New York state per year Seiden,S.C . et al. (2006). Wrong-side/wrong site, wrong-procedure, and wrong-patient adverse events. Arch Surg 141 , 931-939. Kwaan MR et al. (2006). Incidence, patterns, and prevention of wrong-site surgery. Arch Surg 141 , 353-358. Next Slide

8. Incorrect Surgery & Procedures While incorrect surgery & procedures may be uncommon the results can be quite devastating to patients. In addition to patient harm and loss of trust in the healthcare system, there are additional negative consequences including: ‘Second victim’-healthcare providers State licensure board penalities Insurer non-payment for ‘never event’ Malpractice claims-’indefensible’ Next Slide

9. Incorrect Surgery & Procedures Changing the Patient Safety Culture “Suspend every healthcare worker who makes an error today and the error rate tomorrow . . . . . . will be exactly the same as today.” Betty Shultz RN CNOR and Mary Jo Steiert RN BSN CNOR. Past President and President of AORN. Next Slide

10. Incidence of Incorrect Procedure The Joint Commission Stahel , P.F. et al. (2010). Wrong-site and wrong-patient procedures in the Universal Protocol era. Arch Surg , 145, 978-984. Next Slide

11. Sentinel Events The Joint Commission 1995-2010 Next Slide

12. Florida Code 15 Adverse Event Data 1990-2003 Next Slide Types of Incorrect Procedures

13. VHA Incorrect Procedures 2001-2006 Neily J et al. (2009). Incorrect surgical procedures within and outside of the operating room. Arch Surg 144, 1028-1034. This graph demonstrates that half of incorrect surgery & procedures occur outside the operating room. Next Slide

14. Causes of Incorrect Procedures Emergency cases Unusual physical characteristics & equipment set up Multiple procedures and / or surgeons Time pressures Communication breakdown Inadequate preoperative assessment Inadequate procedures to verify correct surgical site Organizational culture Emergency Care Research Institute ( ECRI) (2003). Wrong-site surgery. Healthcare Risk Control, 26. Retrieved from : https://www.ecri.org/Pages/default.aspx Next Slide

15. Causes of Incorrect Surgery - VHA Neily J et al. (2009). Incorrect surgical procedures within and outside of the operating room. Arch Surg,144, 1028-1034. Next Slide

16. Cost of Incorrect Procedures Kwaan MR et al. (2006). Incidence, patterns, and prevention of wrong-site surgery. Arch Surg , 141, 353-358. Next Slide

17. Cost of Incorrect Procedures Wrong site surgery can be devastating for patient and have a negative impact on surgical team. State licensure boards penalties. Insurers may not pay for wrong site surgery. Malpractice claims 84% lead to malpractice awards Average indemnity payment $54,790 Wrong cervical disc removed $1,175,000 Next Slide

18. Exercise What did you find most Surprising about the background information on incorrect surgery? ? Do you currently conduct a “time out” prior to every invasive procedure, even those outside the operating room? ? Next Slide

19. Five Steps to Ensure Correct Surgery & Invasive Procedures Veterans Health Administration (VHA) VHA Directive 1039 requires five steps to ensure correct invasive procedures inside or outside the operating room: Consent process administered and executed for the appropriate procedure. Operative site is marked. Patient and procedure site are identified using a standardized approach. Medical Images reviewed by two members of the procedure team. Time-out facilitated by checklist occurs immediately prior to start of the procedure. Next Slide

20. Five Steps to Ensure Correct Surgery & Invasive Procedures Valid Consent Language understandable by patient Identifies the procedure site, including laterality if applicable Name of procedure Brief description of procedure Reason (condition or diagnosis) for performing the procedure Next Slide

21. Five Steps to Ensure Correct Surgery & Invasive Procedures Marking the Site How? Precise, unambiguous (Do not use ‘X’, Do use “Initials of Provider”) Visible after anticipated prep & drape By whom? Physician doing the operation or invasive procedure Operating team member, who will be present in the operating or procedure room during the procedure, and is appropriately privileged Scheduled anesthesia provider, who must then review the site with another member of the operating team prior to the patient entering the operating or procedure room Next Slide

22. Five Steps to Ensure Correct Surgery & Invasive Procedures Patient and Procedure Site Identification Staff asks patient to verbally state Patient’s name Location of procedure on patient’s body Facility-approved unique identifier (SSN, date of birth) Next Slide

23. Five Steps to Ensure Correct Surgery & Invasive Procedures Medical Images Reviewed Two members of procedure team Physician performing the procedure Second team member may be non-physician Verification by both members Studies available Properly labeled Properly presented Next Slide

24. Five Steps to Ensure Correct Surgery & Invasive Procedures Time-Out Who? Privileged provider performing procedure Nursing staff member Anesthesia provider –if applicable When? Immediately prior to start of procedure How? Facilitated by a checklist Team members verbally concur Documented in electronic medical record Next Slide

25. Five Steps to Ensure Correct Surgery & Invasive Procedures Time-Out Checklist VHA Directive 2010-023 Correct patient identity Procedure to be performed Site of procedure Laterality Valid consent form Patient position Procedure site marked Visible after prep & drape Pertinent medical images confirmed Correct implant(s) available Antibiotic prophylaxis DVT prophylaxis Blood availability Special equipment available Checklist is a “read and verify” format. Each element verbally confirmed by team members prior to starting the procedure. Next Slide

26. Exercise Exercise Were you previously aware of VHA policy or the five steps to ensure correct surgery & invasive procedures ? Take a moment and recall the five steps now ? Next Slide

27. Time Out Procedures Time out procedures are effective in intercepting incidents ( but not 100%) Why do we still have wrong site, wrong procedure, and wrong patient operations? Time out not performed Quality of time out……… “Ambivalent Compliance” Next Slide

28. Time Out Procedures SURPASS ( SURgical PAtient Safety System) Study Self-report versus real-time observation of time outs (n=250 procedures) 172 (68%) one or more of the time out elements were not performed 35 (14%) of the omissions involved verification of operative site marking Self-report of time outs is not reliable Direct observation of time outs remains gold standard……….expense, practicality ? s De Vries EN et al. (2009). Implementation and effectiveness of a time-out procedure. International Forum on Quality and Safety in Healthcare. Retrieved from: http://qualitysafety.bmj.com/content/18/4/e1.extract Next Slide

29. Obstacles to Effective Teamwork Multi-professional workplace (e.g. Surgery, Anesthesia, Nursing, Other) Hierarchical team culture - authority gradients may inhibit team members from “speaking up” when “something not quite right” Team stability, cohesion, leadership all impacted by rotation of team members during a typical day in the operating room Performance affected by chronic staff shortages, and economic/operational pressures Culture & training still promotes autonomy and individualism Limited education regarding understanding error in a systems context Responsibility for policy implementation many times delegated to senior nurse managers Implementation not whole-heartedly supported by senior surgeons sdjf Next Slide

30. Crew Resource Management Communication & Teamwork Techniques Using all available resources – information, equipment, and people – to achieve safe and efficient operations. Musson D, Helmreich RL. (2004). Team training and resource management in health care: Current issues and future directions. Harvard Health Policy Review, 5, 25-35. Next Slide

31. Crew Resource Management United Flight #173 Some of the principles of CRM are best exemplified via the narrative of the crash of a commercial airliner in 1978, in Portland, Oregon-United Flight #173. During preparations for landing, a landing gear indicator light did not display “green”. The pilot and crew placed the aircraft in a circling pattern while trouble-shooting. The pilot became pre-occupied and unaware of the fuel remaining. The co-pilot and flight engineer were aware of the critical fuel level but did not communicate this to the pilot in a timely fashion or with a sense of urgency. The plane crashed. Next Slide

32. NTSB Findings and Recommendations United Airlines Flight #173 Situational Awareness “Failure of the captain to monitor the aircraft’s fuel state… preoccupation with landing gear…” “Speaking Up” “The failure of the other two flight crewmembers…to successfully communicate their concern to the captain .” Crew Resource Management Next Slide

33. Vertical Hierarchy Obstacle to Speaking Up Carney BT et al. (2010). Differences between nurse and surgeon perception of teamwork. AORN Journal, 91, 722-729. Next Slide

34. Situational Awareness The perception of environmental elements within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future. Endsley M. (1995). Toward a theory of situation awareness in dynamic systems. Human Factors 37, 32-64. Next Slide

35. Situational Awareness Threats / Stressors Garland, Wise & Hopkin , 1999 Handbook of Aviation Human Factors Mental Load Task Load Time Pressure Distractions Fatigue Attentional Narrowing Limited Attention Working Memory ERROR “CFIT” Wrong Site Surgery Next Slide

36. Read Back / Repeat Back Closed Loop Communication Read Back Write down what you heard Read back what you wrote Confirm with the sender Repeat Back Reflect back what you hear Confirm with sender VHA Directive 2010-023 4b(2) Next Slide

37. Read Back / Repeat Back Tenerife Disaster, 1977 KLM Co-Pilot: “We’re at take-off” Control Tower: “OK” Next Slide

38. Step Back Reassess a situation that doesn’t appear to be working. Take a brief pause in the action Challenge all previous assumptions Next Slide

39. Step Back Fixation Error - This and Only This Eastern Flight #401, Miami, Florida 1972 Next Slide

40. Two Attempt Rule Assure that critical information is communicated to the right person If no response, a second assertive statement is made Next Slide

41. Two-Attempt Rule First Officer: “ I am concerned. There is ice forming on our wings.” Pilot : (Does not respond, continues to taxi). First Officer : “ Bob, there is ice on the wings, we need to return for de-icing. Do you want to contact the Tower or shall I?” Next Slide

42. Conclusion What you have learned: Definition, incidence, and causes of incorrect surgery & invasive procedures The five steps to ensuring correct surgery & invasive procedures Consent Patient identification Mark the site Medical images Time out Next steps: The next page contains references for this course you may be interested in When you finish, enter the on-line virtual patient simulation to practice your skills Take the exam/test Next Slide

43. Patient Safety for Residents ‘Time Outs’ References Kwaan , M.R., Studdert , D.M., Zinner , M.J., Gawande , A.A. (2006). Incidence, patterns, and prevention of wrong-site surgery. Arch Surg,141 , 353-358. Neily, J., Mills, P.D., Eldridge, N., Dunn, E.J., Samples, C., Turner, J.R., Revere, A., DePalma , R.G., Bagian, J.P. (2009). Incorrect surgical procedures within and outside of the operating room. Arch Surg,144 ,1028-1034. Stahel , .PF., Sabel ,A.L., Victoroff , M.S., Varnell , J., Lembitz , A., Boyle, D.J., Clarke, T.J., Smith, W.R., Mehler , P.S. (2010). Wrong-site and wrong-patient procedures in the Universal Protocol Era. Analysis of a prospective database of physician self-reported occurrences. Arch Surg,145, 978-984. VHA Directive 2010-023. Ensuring Correct Surgery and Invasive Procedures. Retrieved from: http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2243 Next Slide

44. Ensuring Correct Surgery & Invasive Procedures National Center for Patient Safety (NCPS) Workgroup Lori DeLeeuw, R.N., M.S.N. Laura J. Hoeksema, M.D. Aartee Ignaczak, M.P.H. Caryl Z. Lee, R.N., M.S.N. Lisa M. Mazzia, M.D. Cheryl A. Mitchell, R.N., B.S.N., M.S.A. Tina Nudell, M.S. Douglas E. Paull, M.D. Seth Wolk, M.D., M.H.S.A. Scott Wood, PhD Next Slide