The event of wrong-site surgeries has become an issue of concern in the medical field. The patient safety incidence made national headlines in 1995 when a man had the wrong leg amputated in a hospital in Florida. The Institute of Medicine published a report, To Err Is Human: Building a Safer Health System , in 2000 that indicated that despite the advanced experience of many medical practitioners, the incidence of error is likely to occur. Using this perspective thinking, it is evident that members of the society are likely to experience medical errors that may have negative consequences on the patient. The report triggered a national movement that would prompt development of measures to reduce such occurrences. There have been substantial efforts made to improve quality and safety issues in the healthcare sector. However, the incidence of wrong-site surgeries have been recurrent up to 40 times in a week a clear indicator of the need to develop measures that can prevent the issue (Fields, 2012). The following memo is intended to provide respective professionals involved to ensure that the issue is turned into a ‘never’ event.
Organizational Culture
One of the most influential factors in the wrong-site surgeries is the culture of a health organization. There have been a growing number of hospitals and healthcare organizations that applying observations from other companies in other industries in reference to safety and hazardous events. The most important lesson learnt from the monitored organizations is the needs for a culture of safety (Chassin, 2013). Despite the diverse practices and operations of these corporations, they have a common factor in that they are able to maintain high levels of safety standards. Each employee is aware of the key role played in achieving this standard. They also have an obligation to report cases of conditions that may be unsafe or inappropriate behavior by their superiors and peers alike (Chassin, 2013). The measure is an effective means of developing a culture of safety in the organizational practices. These efforts by employees to comply with safety rules enable the institution to develop effective practices that will remedy the issue in question. In the health sector, hospitals can emulate the high compliance standards in organizational culture similar to nuclear plants seeking to prevent employee exposure to the hazardous materials. It would be inconceivable for workers in the latter case to demonstrate compliance rate of 40% which is common in health organizations (Chassin, 2013).
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Developing Case Specific Protocol
When the wrong-site surgeries became an issue of concern in the health sector, various governing bodies sought to develop an appropriate means of alleviating the problem. The American Academy of Orthopedic Surgeons (AAOS) and North American Spine Society (NASS) have been involved in reviewing cases of malpractice in the industry (Hanchanale, Rao, Motiwala, & Karim, 2014). The former prompted a campaign that would encourage signing the right surgical sight and an additional warning to the incorrect site. It is evident that these measures are appropriate to eradicating the issue completely, the incidence of the medical error continues (Hanchanale et al., 2014). This indicator shows that a single measure cannot effectively eliminate the occurrence of wrong-site surgeries. Surgical experts and other members of the medical field should develop measures that will address each case independently. The most common theme over the past two decades in efforts to improve quality is best practice where ‘one size fits all’. The ideal has not borne fruit hence the need to identify alternative measures to take.
Interprofessional Teamwork
Following the recent concerns of patient safety and the quality of care provided, the cooperation of clinicians has been touted as the most appropriate solution for the problems. Interprofessional collaboration has been defined as the harmonious organization of medical practitioners to achieve the best possible outcome for the patient (Fields, 2012). Wrong-site surgery may involve operations on the wrong side or incorrect body site significantly causing unnecessary harm on the patient. A recent study showed that these errors rarely take place in surgical procedures at a rate of 1 in 112,000 cases meaning it a single error could occur in 5 to 10 years in an individual hospital (Fields, 2012). However, when taking into consideration procedures taking place in other departments of the institution, the rate significantly increases to over 50%. It is evident that interprofessional collaboration would help in reducing such incidences (Hanchanale et al., 2014). Communication and coordination between the operating room personnel and others from the different departments could help improve the outcomes realized.
Training Staff Members
Surgical checklists were developed to prevent errors such as wrong-site surgery after observations were made in the aviation industry. Numerous accidents that were caused by human errors were identified as avoidable if an appropriate checklist would be formed. In the operating room, there are many significant things that should be done pre-procedure and before incision (Health Research & Educational Trust and Joint Commission Center for Transforming Healthcare, 2014). As a result, forgetting any one of them could be catastrophic to the entire process. All participating healthcare personnel should be acquainted to the surgical checklist and recognize the role they play in checking off items and steps before surgery takes place. An appropriate training session may be instituted for all operation room staff and teams that participate in any surgical procedures (Glymph et al., 2015). The hospital administration should also emphasize the importance of the checklist and should have a no-tolerance policy to cavalier attitudes toward the process. This is an effective measure of developing a culture towards safety measures in the OR processes and in ensuring positive outcomes for the patient.
Patient Involvement
During the process of identifying the appropriate strategies for eradicating wrong-site surgeries, it is evident that patient involvement is a suitable practice for achieving this objective goal. The OR team should keep the patient awake during the entire process of confirming the checklist (Glymph et al., 2015). The patient will confirm the correct side and site that the surgery should take place. Patients are more likely to feel confident of the appropriate surgical site when they are involved in the process. In some cases, there have been propositions that the patient should also sign on the required site when possible. This practice is incorporated particularly in limb surgeries and when the patient can reach the site in question. Patient involvement also ensures that communication is done in cases where errors are noted in procedures carried out in other departmental settings outside the OR (Glymph et al., 2015). The circulating nurse can communicate with other members of staff in the hospital to confirm the surgical site.
Monitoring Implementation of Checklist
The final strategic measure that the organization can employ in developing an appropriate measure for reducing cases of wrong-site surgeries is monitoring the various interventions that the hospital has instituted (Fields, 2012). Health organizations will usually employ one or two measures of eradicating the medical error. The Joint Commission identified that wrong-site, patient, and procedure surgeries were the most sentinel events reported through September 2015. A total of 1,196 cases were reported followed by 1,072 in unintended retention of foreign objects, 1,035 treatment delays, 932 suicide, and 904 complications in operative or postoperative procedures (Health Research & Educational Trust and Joint Commission Center for Transforming Healthcare, 2014). Institutions seeking to eradicate the incidence of such medical errors will look into identifying its base events prior to implementing interventions for the problem. This will be used to monitor if any progress is being made towards improving the quality and safety of the care provided to the patient (Fields, 2012). Research has shown that more than half of these cases will usually result in death, unnecessary additional care, and permanent loss of function. Such outcomes will also be included in assessing the efficacy of the changes that are made in the surgical and organizational processes.
References
Chassin, M. R. (2013). Improving the quality of health care: what’s taking so long? Health Affairs, 32 (10), 1761-1765.
Fields, R. (2012) 8 Strategies to Prevent Wrong-Site Surgery . Becker’s Clinical Leadership & Infection Control, Retrieved from https://www.beckersasc.com/asc-quality-infection-control/8-strategies-to-prevent-wrong-site-surgery.html
Glymph, D. C., Olenick, M., Barbera, S., Brown, E. L., Prestianni, L., & Miller, C. (2015). Healthcare utilizing deliberate discussion linking events (HUDDLE): A systematic review. AANA J, 83 (3), 183-188.
Hanchanale, V., Rao, A. R., Motiwala, H., & Karim, O. A. (2014). Wrong site surgery! How can we stop it? Urology Annals, 6 (1), 57-62.
Health Research & Educational Trust and Joint Commission Center for Transforming Healthcare. (2014). Reducing the risks of wrong-site surgery: Safety practices from The Joint Commission Center for Transforming Healthcare project . Chicago, IL: Health Research & Educational Trust. Retrieved from http://www.hpoe.org/Reports-HPOE/Wrong_Site_Surgery_Guide_2014.PDF
