Santa Not the Only One With a Checklist
by Richard J. Bocklett
Dec 17, 2008 | 15555 views | 0 0 comments | 626 626 recommendations | email to a friend | print
A medical team at Elmhurst Hospital goes through a surgical safety checklist prior to induction of anesthesia.
A medical team at Elmhurst Hospital goes through a surgical safety checklist prior to induction of anesthesia.
After heart disease and cancer, medical errors are the third leading cause of deaths in the United States, a fact that is prompting hospitals across the city to modify their procedures.

An average of 195,000 people in the United States died due to potentially preventable, in-hospital medical errors from 2000 to 2002, according to a 2004 study of 37 million patient records that was released by HealthGrades, the healthcare quality company.

“That is the equivalent of 390 jumbo jets full of people are dying each year due to likely preventable, in-hospital medical errors, making this one of the leading killers in the U.S.,” said Dr. Samantha Collier, HealthGrades' vice president of Medical Affairs.

The World Health Organization (WHO), which has a worldwide Safe Surgery Saves Lives campaign, reports that in the developed world, nearly half of all harmful events (such as miscommunication, wrong medication, and technical errors) affecting patients in hospitals are related to surgical care and services. The evidence suggests that at least half of these events are preventable if standards of care are adhered to and safety tools, such as checklists, are used.

Preliminary results of an evaluation in eight pilot sites worldwide show that the checklist has nearly doubled the likelihood that patients will receive treatment as per standards of surgical care – such as an antibiotic before incision and confirmation that the surgery team has the correct patient for the correct operation.

Attempting to enhance error reduction strategies and strengthen checks and balances, all 11 New York City public hospitals will employ Verbal Surgical Safety Checklist procedures in their operating rooms by year’s end.

“In New York and nationwide, we’re becoming more aware of the problem of medical errors and even one mistake is one mistake too many,” explained Dario Centorcelli, associate executive director for External Affairs at Elmhurst Hospital Center. “The country is turning more to patient safety and our new operating room safety procedure is one important step in that direction.”

Since June, Elmhurst has been one of five city hospitals piloting and refining the new procedures. While all hospitals use a written surgical safety checklist, Elmhurst employs both written and verbal measures to boost patient safety.

“Enhanced verbal communication forces the patient and all team members - surgeons, nurses, and anesthesiologists - to be sure it’s the right patient undergoing the right procedure at the correct site with the proper consent in hand,” explained Anne McCann, associate executive director for Perioperative Services.

“Before, we used the written checklist alone, but now it’s also verbal,” she continued. “It’s like a huddle, with the patient in the middle and everybody speaking to each other about what’s going to happen.”

While other hospitals solely rely on the written checklist, McCann insists the dual approach is better.

“Remember, the doctor is not going to read everything the nurse wrote,” she said, “but when I ask the patient aloud if he’s adverse to any drugs, has allergies and so forth, now everyone hears his answer.

“Around the country, patients have been victims of wrong site surgery,” she continued. “Recently in Boston, for example, surgeons operated on the wrong knee because the x-ray images weren’t displayed properly.”

In a very controlled situation, every checkpoint must fall in place or the procedure can’t move on.

“Initially, it was a cultural change for all of us, but now it’s become a pleasant experience,” McCann said.

The chairman of Surgery at Elmhurst, Dr. Unsup Kim, helped initiate the new operating room procedure from the pilot stage. Developed and fine-tuned on a one-day-a-week basis, the idea was fully integrated into the Elmhurst hospital routine in August. Now, he’s teaching the medical residents the benefits of the program.

Here’s how it works: Before the induction of anesthesia, the operating room team verbally reviews with the patient his identity, that the procedure and the operational site are correct, and that his consent has been given.

All then view the site and make sure a pulse oximeter - which registers pulse rate and oxygen saturation - is on the patient and functioning correctly. The anesthesiologist and surgeon review the risk of blood loss, allergic reactions, airway difficulties, and other complicating factors before the type of anesthesia is chosen. Then, a full anesthesia safety inspection is done.

“The most important point is that all members of the three-part surgical team communicate and understand what we are going to do by exchanging and verifying information,” Kim said. “For example, regarding patient identification, in this hospital there’s a lot of people named Rodriquez. So we must check that it’s the right person by medical record number and by date of birth, both in the holding area as well as again in the operating room.”

Operational site verification, often with a felt pen marking the designated spot, is important. When there are two similar organs, confusion can ensue.

“In Florida, less than a year ago,” Kim noted, “they amputated the wrong leg. Believe me, it happens.”

Prior to incision, the team verbally reviews the operating time frame, anticipated as well as unexpected events, such as heavy blood lose, and the steps that might have to be taken. The nursing team reviews whether there are any sterility problems with the instruments or in the room.

Patient infection is a big concern during operations. Ordinarily, the immune system controls bacteria but once the incision is made exposure to bacterial infection rises. The WHO reports that safety measures are inconsistently applied in surgery, even in sophisticated settings, and that simple steps, like hand scrubbing with an alcohol-based solution, can substantially lower the complication rates. And, improving the timing and selection of antibiotics prior to skin incision can reduce the rate of surgical site infections by up to 50 percent.

The anesthesiologist confirms that prophylactic antibiotics have been administered in the last 60 minutes and the scrub nurse verifies that sterilization procedures have been performed. The team checks that essential x-ray imaging is completely and properly displayed. Such imaging is critical to procedures like orthopedic, spinal and thoracic surgery and many tumor resections.

In the wound closure phase before the patient leaves surgery, biopsies from different parts of the body, such as samples from the right and left breast, must be properly stored and clearly labeled for analysis in the pathology lab. The circulating nurse reads aloud the patient’s name and specimen description to confirm correct labeling

Surgical instruments, needles and sponges are counted by kind and number, and all must be recovered.

“You don’t want to have a sponge or an instrument left in the belly,” explained Kim. “If you’re not careful, this retained material can happen during emergency surgery when everyone is doing his best to save a life.”

McCann concluded with the following message to patients in New York City hospitals.

“We want our citizens to be assured that when they come in for surgery, they’ll get the correct procedure,” she said.

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