(Original article is here.)
Hospitals work on getting it right (or left)
- Article by: JACKIE CROSBY , Star Tribune
- Updated: June 19, 2011 - 9:57 PM
Wrong-site surgeries continue to plague hospitals, but a new campaign hopes to ensure everyone takes a "timeout" before surgery.
As 4-year-old Josiah lay sedated on the operating table one recent morning at Amplatz Children's Hospital, as many as 10 people swirled in the room around him. With rock 'n' roll playing in the background, they hooked up monitors, gave him medication and adjusted his tiny body to prepare him for the expected 4-hour surgery on his esophagus.
Scrubbed and in his gloves, surgeon Daniel Saltzman signaled a nurse to turn off the music.
"OK," he said. "Let's do the timeout."
All activity stopped. Hands rested on the operating table. Nurse Katy Mokita stood at the foot of the bed and read from a release that included the patient's name and the surgery about to be performed. One by one, those around Josiah introduced themselves by name and stated their roles in the operation. Saltzman, chief of pediatric surgery at the University of Minnesota hospital, spoke last.
But before he was handed the scalpel, scrub technician Christina Dyer moved a bright yellow sticker that screamed "PAUSE," in capital letters, from the tool tray.
Experts say this "timeout" procedure, which lasted less than a minute, is critical to eliminating preventable mistakes in the operating room. Yet despite several years of promoting timeouts, Minnesota hospitals and surgery centers reported 48 wrong surgeries in the most recent 12-month reporting period -- the highest number since the state began collecting data in 2004.
Although no deaths were reported during the period, the stakes are high. Mistakes can be lethal, or lead to serious disabilities and lifelong problems.
"Timeouts aren't being done 100 percent of the time, and that needs to change," said Lawrence Massa, president of the Minnesota Hospital Association.
The group launched a three-year timeout campaign last week to draw attention to wrong-site surgeries, which accounted for two-thirds of wrong-surgery mistakes.
With wrong surgeries, the steps aren't consistently followed from hospital to hospital or they become so routine that minds wander. The result is that the right hip gets replaced instead of the left. Or the pain medication gets delivered to the wrong body part. Or one patient gets a procedure meant for someone else.
The campaign includes such things as new posters for operating rooms, "I pledged" stickers like those given out on election day, and a website that counts the number of days since the last wrong-site procedure.
Other sponsors include the Minnesota Department of Health, the Minnesota Medical Association and MMIC, a medical liability insurance group.
The goal is zero wrong-site surgeries, said Massa, noting that hospitals have made progress reducing serious falls and other preventable incidents. "That's a lofty goal, but that's the game plan."
Wrong surgeries are rare, making up about 1 in 60,000 procedures, according to the Minnesota Department of Health. But the Hospital Association became so concerned about the rising trend last June, it sent out an alert to all of its members . It warned that 38 percent of wrong-site cases had happened when the procedure was correctly marked on the patient, but no one on the surgical team had looked for the mark before starting.
By that point, it's difficult for anyone to speak up, said Kathleen Harder, director for the Center for Design in Health at the University of Minnesota who has spent a decade studying ways to reduce surgical mistakes.
Harder, a cognitive therapist, has streamlined the procedure, which now works like the timeout that took place before Josiah's surgery at Amplatz. Harder is in the process of training surgical staff across the state as part of the Hospital Association's awareness campaign.
"The changes are dramatic," she said. "I no longer see this chaotic environment."
Harder visited eight surgery centers around the state and realized there were too many steps in previous timeout procedures many hospitals had adopted in recent years. The timeout began before the surgeon was scrubbed. People were going through rote statements, or continuing to work during the drill.
The new approach "channels behavior" so people in the operating room can't multitask, she said.
A facility in Colorado that implemented her timeout procedure caught a mistake in the first week, she said.
Dr. Jeffrey Chipman is a champion for timeouts at the University of Minnesota Medical Center. He said the role "provides a face to the problem, rather than another mandate from an impersonal institution." It doesn't hurt, he said, when a champion can share a personal story about how the process saved him or her from a mistake.
Regions Hospital in St. Paul began rolling out its own internal patient safety campaign this summer that drew the attention of U.S. Health and Human Services Secretary Kathleen Sebelius earlier this month. The hospital uses the overhauled timeout procedure and is focusing on changing culture -- a much more difficult thing to do.
Scrubbed and in his gloves, surgeon Daniel Saltzman signaled a nurse to turn off the music.
"OK," he said. "Let's do the timeout."
All activity stopped. Hands rested on the operating table. Nurse Katy Mokita stood at the foot of the bed and read from a release that included the patient's name and the surgery about to be performed. One by one, those around Josiah introduced themselves by name and stated their roles in the operation. Saltzman, chief of pediatric surgery at the University of Minnesota hospital, spoke last.
But before he was handed the scalpel, scrub technician Christina Dyer moved a bright yellow sticker that screamed "PAUSE," in capital letters, from the tool tray.
Experts say this "timeout" procedure, which lasted less than a minute, is critical to eliminating preventable mistakes in the operating room. Yet despite several years of promoting timeouts, Minnesota hospitals and surgery centers reported 48 wrong surgeries in the most recent 12-month reporting period -- the highest number since the state began collecting data in 2004.
Although no deaths were reported during the period, the stakes are high. Mistakes can be lethal, or lead to serious disabilities and lifelong problems.
"Timeouts aren't being done 100 percent of the time, and that needs to change," said Lawrence Massa, president of the Minnesota Hospital Association.
The group launched a three-year timeout campaign last week to draw attention to wrong-site surgeries, which accounted for two-thirds of wrong-surgery mistakes.
With wrong surgeries, the steps aren't consistently followed from hospital to hospital or they become so routine that minds wander. The result is that the right hip gets replaced instead of the left. Or the pain medication gets delivered to the wrong body part. Or one patient gets a procedure meant for someone else.
The campaign includes such things as new posters for operating rooms, "I pledged" stickers like those given out on election day, and a website that counts the number of days since the last wrong-site procedure.
Other sponsors include the Minnesota Department of Health, the Minnesota Medical Association and MMIC, a medical liability insurance group.
Goal: Zero wrong surgeries
Wrong surgeries are rare, making up about 1 in 60,000 procedures, according to the Minnesota Department of Health. But the Hospital Association became so concerned about the rising trend last June, it sent out an alert to all of its members . It warned that 38 percent of wrong-site cases had happened when the procedure was correctly marked on the patient, but no one on the surgical team had looked for the mark before starting.
By that point, it's difficult for anyone to speak up, said Kathleen Harder, director for the Center for Design in Health at the University of Minnesota who has spent a decade studying ways to reduce surgical mistakes.
Harder, a cognitive therapist, has streamlined the procedure, which now works like the timeout that took place before Josiah's surgery at Amplatz. Harder is in the process of training surgical staff across the state as part of the Hospital Association's awareness campaign.
"The changes are dramatic," she said. "I no longer see this chaotic environment."
Harder visited eight surgery centers around the state and realized there were too many steps in previous timeout procedures many hospitals had adopted in recent years. The timeout began before the surgeon was scrubbed. People were going through rote statements, or continuing to work during the drill.
The new approach "channels behavior" so people in the operating room can't multitask, she said.
A facility in Colorado that implemented her timeout procedure caught a mistake in the first week, she said.
Giving the problem a face
Regions Hospital in St. Paul began rolling out its own internal patient safety campaign this summer that drew the attention of U.S. Health and Human Services Secretary Kathleen Sebelius earlier this month. The hospital uses the overhauled timeout procedure and is focusing on changing culture -- a much more difficult thing to do.
"Speaking up can be scary unless you create a culture of robust leadership and have surgeons engaged that will celebrate near misses, celebrate people stopping the line," said Dr. Gary Collins, a trauma surgeon at Regions.
Collins said it's important to convince people that it won't increase work flow, and that the procedures don't get audited in a "shameful way."
"It's about shifting the culture from, 'Yeah that happens once in a while,' to 'that can't ever happen. One is too many.'"
Jackie Crosby • 612-673-7335
Collins said it's important to convince people that it won't increase work flow, and that the procedures don't get audited in a "shameful way."
"It's about shifting the culture from, 'Yeah that happens once in a while,' to 'that can't ever happen. One is too many.'"
Jackie Crosby • 612-673-7335
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