From the Chief Medical Officer's Desk
“The second step in the right direction is often the most difficult”- Theo Menstrum
Several years ago, we implemented the surgical time out to decrease the number of wrong sided surgeries and believed our sponge and instrument counts would keep us from having any retained foreign objects. Though our numbers have decreased, we continue to have wrong sided surgeries, wrong procedures on patients and retained foreign objects. This graph of analysis of sentinel events that occurred within Banner in 2010 shows that improving the safety of our surgery remains the greatest opportunity to improve safety for our patients, our staff and our physicians. Remember, these mistakes can affect everyone on the team.
On May 5th, we will be implementing an expanded version of the Safe Surgery and Count process which some of our physicians have had a significant part in developing (thank you Drs Schuster, Dahl and Sodoma.). Both the University of Minnesota Medical Center in Fairview and the Christiana Care Health System eliminated retained foreign objects for 4 years after implementing this process and University of Minnesota eliminated all wrong site, wrong procedure and wrong patient surgeries in 2009. The key to this is cognitive cngagement by all members of the team for the task at hand. A detailed letter has been sent to the medical staff.
The major parts will have everyone, including the surgeon, checking the patient’s name and ID band, verifying orders and consents, marking the site with the patient (as before). In the OR, there is a briefing with introductions of the staff to assure all in the room are on the same page (cognitive engagement), the time out, the count and a quick debrief. This debrief makes sure that pathology requests will be handled appropriately, a chance for the team to discuss what went well and what needs to be changed and a chance to update preference cards.
Analysis of human errors have found that cognitive errors can be significantly decreased with cognitive engagement. How often do we instinctively head towards the office or the hospital on the weekend when we are intending to drive elsewhere? How often do we make errors in our lives by not paying attention?
"Few of us ever live in the present. We are forever anticipating what is to come or remembering what has gone." — Louis L'Amour