Surgical Specimen Errors in the Operating Room

Improving Quality of Care in Surgical Care

Surgical Safety Program MCIC-Vermont

The Race to Improve Safety in U.S. Hospitals

Why the hysteria?

Institute of Medicine Report

U.S. Malpractice Crisis

Where We Stand

Quality (error rate)

Low

High

Low

High

U.S. Postal Service

Hotels

Health Services

Auto Manufacturing

Food Services

Airlines

Tobacco

Computers

Industries by Size, Productivity, and Efficiency

*Source: Advisory Board Company, 2005

How do we know we are safer?

Central Mandate

Local Wisdom

Scientifically Sound Feasible

Finding the Sweet SpotA Model for Improving Safety

Makary MA, et al. Patient Safety in Surgery, Annals of Surgery, 2006

Attributes of System Level Measure for Safety

• Scientifically sound, feasible, important, usable

• Apply to all patients

• Aligned with value; encourage desired behaviors

• Meaningful to front-line staff who do the work

Why do Errors Occur in the Operating Room?

Root causes Analysis*

*Joint Commission on Accreditation of Healthcare Organizations. Sentinel Events : Evaluating Cause and Planning Improvement. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 1998.

*Joint Commission on Accreditation of Healthcare Organizations. Sentinel Events : Evaluating Cause and Planning Improvement. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 1998.

The Hierarchy of the Medicine

Safety and Communication

Teamwork in the Eye of the Beholder

Makary M, Sexton JB, Freischlag JA., et al. Teamwork in the Operating Room. J Am Coll Surg, 2006

Perceptions of Good Teamwork and Collaboration

48%

88%

0

10

20

30

40

50

60

70

80

90

100

S u rg

Nurse Rates Surgeon Surgeon rates Nurse

Familiarity with others is a critical component of effective teamwork

Aviation Data

•74% of all commercial aviation accidents happen on the first day of a crew flying together

OR Briefing Checklist

Time-Out

Antibiotics

DVT Prophylaxis

Instruments and Equipment

Identify Team

Makary M, Holzmueller C, Rowen L., et al. Operating Room Briefings. Joint Commission Journal Qual & Safety, 2006

Surgical Specimen Handling

THE PROCESS

• Surgeon passes the specimen to the Scrub Nurse or Tech

• The specimen is then passed to the OR Circulator

• The Circulator obtains from the surgeon the name and laterality of the specimen

Surgical Specimen Handling

• A critical point of communication among OR providers

• Significant Implication for patient care– Cancer diagnosis– Laterality

• Measurable in a standardized fashion

Mislabeled Specimen Error Types

No labelNo label

No specimenNo specimen

Incorrect LateralityIncorrect Laterality

Incorrect Tissue Incorrect Tissue SiteSite

Incorrect PatientIncorrect Patient

No Patient NameNo Patient Name

No Tissue SiteNo Tissue Site

No Clinical HistoryNo Clinical History

The Goal: Measuring Quality

0

2

4

6

8

10

12

14

16

18

Specimen NotLabeled

EmptyContainer

LateralityIncorrect

IncorrectTissue Site

IncorrectPatient Name

No PatientName

No TissueSite Identified

The Intervention

• A Verification Step to Check Specimen in the same way blood is checked before use

• Nurses read back the specimen name

• Surgeon to sign off after each case

• Mislabeled Specimens tracked at surgical pathology receiving desk

The Debriefing

Verify the Specimen

Were there any issues encountered?

What could have been done to make the case more efficient?

What could have been done to make the case safer?

Signature _______________________

Conclusions

• Communication and Teamwork are associated with patient outcomes

• Mislabeled surgical specimens represent a measurable and preventable error in the surgical setting

• Surgical Specimen Labeling errors are a surrogate of poor communication in the OR

• A surgical specimen checklist, similar to checking blood products, can improve quality in the OR