JURNAL KEPERAWATAN : Time out is just another way to say communicate

Sumber : Eileen Corley MSN, RN, CNOR Ms. J, born on 3/14/1951, saw a physician assistant (PA) in early January with pain in both knees (right greater than left). Following several weeks of physical therapy, the pain was still present, so Ms. J scheduled another visit. This time, she saw an orthopedic surgeon at a satellite office. The surgeon examined the knee and felt that arthroscopy of the right knee was indicated. The surgeon directed his office staff to schedule an arthroscopy, but the chart was at the downtown office, so the note wasn't entered in the patient record until the next day. A few days later, the case was scheduled. Ms. J reported to the hospital as instructed on February 28. The registration desk was busy, and the clerk forgot to verify the date of birth on the armband, which incorrectly read 3/14/1961. The surgery schedule read "arthroscopy," but didn't indicate which knee. The surgeon was running behind with his first case, so the PA stopped by the holding area to mark the knee before he left to go back to the office. The patient was medicated with midazolam in the holding area. When the PA asked Ms. J if her left knee hurt, she responded yes, and the left knee was marked. The circulating nurse transported her to the OR, checked the consent, positioned the patient, and prepped the knee that was marked. The surgeon scrubbed and came into the OR. When the circulating nurse reminded the surgeon it was time to perform the time out, he said, "I'm already late enough," asked for the scalpel, and made an incision in the left knee. After surgery, Ms. J was dressing to go home and asked the discharge nurse "Why don't I have a bandage on my right knee? That's where I was supposed to have surgery." Changes in healthcare and advances in technology have made every aspect of healthcare more difficult to navigate than ever before. Having the ability to offer various types of surgery with multiple points of entry into the system has created a complex environment that's a breeding ground for errors. Add to that the increasing need for speed in most ORs, and a perfect storm emerges. A wrong-site surgery event isn't just an increased risk for a malpractice claim. Performing a procedure at the wrong site or on the wrong side is a violation of the patient's trust in their healthcare providers. Safety is one of the implicit promises to the patient. Wrong-site surgery is also a devastating event for the healthcare providers involved. The cost to reputations and possibility of fines, malpractice claims, and consequences to licensure are also concerns. In 2005, six-to-seven figure sums were paid on malpractice claims resulting from wrong-site surgery, and one report found a wrong-site surgery suit filed every 5 to 10 years at any given hospital.1 What's wrong-site surgery? Wrong-site surgery is defined as surgery on the wrong patient, wrong procedure (a procedure other than what was intended), on the wrong side (for structures that are bilateral), or on the wrong structure or body part (digit, limb, and the like).1 Clarke and colleagues found that surgery on the wrong side is the most common.1 The Joint Commission (TJC) considers wrong-site surgery a sentinel event. TJC has designated prevention of wrong-site surgery as one of their national Patient Safety Goals.2 Some states have instituted a mandatory reporting system for wrong-site surgery. Occurrence It's difficult to determine the exact rate of occurrence because wrong-site surgery can be reported in several ways. Increased awareness may also improve reporting of wrong-site surgery events and near misses, so it's reasonable to assume that recent focus on prevention of wrong-site surgery has had some effect on reporting. Statistics regarding the incidence of wrong-site surgeries vary. Studies indicate that wrong-site surgery may occur in as many as 1 in 5,000 cases or as few as 1 in 113,000.3 The Veterans Affairs reviewed reports of wrong-site surgery from 2001 to 2006 and found 209 wrong-site surgeries. This equals averages of 1 wrong-site event in every 18,955 surgical procedures.4 In surgery, the highest number of wrong-site procedures involves cataract surgery. This is understandable because both eyes may have cataracts present and the wrong eye may be operated on. Inguinal hernia repair is the second highest procedure with reports of wrong-site surgery.5 Regardless of the numbers reported, wrong-site surgery is defined by TJC as a "never event," recognizing that any occurrence of a wrong-site surgery is life changing for the patient involved.6 It should be the goal of any OR, hospital, and procedural area to never have a wrong-site surgery. Consequences The consequences for patients who have undergone a wrong-site procedure range from life-threatening and debilitating to minor and inconsequential. The error in the OR could be something as minor as a small incision where none should exist to removal of a healthy organ or limb. There are also consequences for the staff and surgeons involved. Some state licensure boards impose penalties, and insurers may cancel coverage for practitioners involved. Involvement in a wrong-site surgery event may also lead to legal action to those involved.3 The punishment those involved inflict on themselves may be even worse. People go into healthcare to help, and it's often devastating to them when they've been a participant in a harmful event. A wrong-site surgery shakes the team member's confidence in their abilities and stays with them forever. Causes of wrong-site surgery It goes without saying that a great deal of planning goes into any surgical procedure. The perioperative staff need to demonstrate satisfactory performance in specific procedural competencies. There are surgeon preference cards that provide information on what instruments, supplies, and suture are required. With so many people rushing around and attending to smaller details, it's easy for the most important and seemingly obvious items to be overlooked. Understanding what type of surgery is being done at what site seems to be a relatively uncomplicated task until one looks at the number of people the information passes through before the patient reaches the OR. The World Health Organization recommends verification at every step in the process of a surgical case and has developed a safe surgery checklist that details what information should be confirmed. The checklist contains preinduction, preincision, and postprocedure details. Patient identification, procedure, and side/site confirmation are included at each of these points.7 Any information that's received verbally (for example, scheduling a case by phone) should be read back and confirmed for clarity. All written information should be checked against any documentation provided by either the surgeon or patient. Information on the surgical schedule must be compared with what's written on the consent form and checked against the surgeon's history, physical, and orders. Ideally, there will be agreement among all of these. If at any time, anyone, including clerical staff, nurses, certified registered nurse anesthetists (CRNAs), or physicians, notices a discrepancy, the patient's progress should halt immediately until variances are resolved. Only then can the patient continue toward the OR. The team as a whole shares responsibility for making sure they're doing the right thing. The traditional culture in the OR is a barrier that's slowly falling but still exists.8 Although the personnel involved in a case must function as a team, there has been a long-standing perception of power differences that often inhibits some team members from feeling that they can be heard. For a time out to truly be a team effort, all members of the team must have a level of comfort and feel that they're empowered to speak up. Culture doesn't change overnight, but it's important that everyone involved in a case has a true understanding of proposed procedures and the ability to stop the process if there is even the possibility of an error. The required culture change requires active support from the top and a clear expectation from administrators that speaking up isn't just an option, it's a requirement. A clear and defined process for reporting deviance from policy auditing performance helps assure that progress is being made. Management presence provides support and underscores commitment to patient safety. Strategy for prevention Several strategies have been developed to help reach that goal. Among these are correctly identifying the patient, identification of the intended surgical site, and the time out prior to any procedural intervention. Step back and take a look at site marking and the time out, and it'll become evident that these strategies are truly just communication tools aimed at increasing effective communication among all team members. Communication has been identified as the most often recognized cause of wrong-site surgery sentinel event.9 TJC reported that poor communication was the cause of nearly 70% of sentinel events in 2005.10 When any project involves potential harm to a person, it's essential that the communication is clear at all times. Any time there is more than one person involved in a project, the potential for poor communication exists. The additional barriers of having new perioperative team members who may not know each other involved in a complex and stressful situation heightens the risk and demonstrates the need that a plan must be in place to decrease the chance of a bad outcome. Every step leading into the OR involves communication between patients, nurses, and physicians. Assuring that cases are posted correctly, that all pertinent and required documentation is present, and that the operative site is correctly identified and marked is a collaborative effort. Before the patient reaches the OR, there are multiple opportunities to identify discrepancies and prevent irreversible harm from occurring. Once the door is closed and the patient is asleep, the circumstances narrow the chances of stopping an error. This is where the time out comes in. TJC recommends that when possible, the patient should be involved in the surgical verification process.11 Each facility is charged with developing its own procedures, and many ORs decide to perform the time out immediately prior to the incision. If the time out is performed after the patient is anesthetized, it's essential that a complementary process be developed to include the patient in the surgical site identification prior to being medicated.6 The time out communication, then, is actually an opportunity for the team to speak on behalf of the patient. The OR team becomes the patient's advocate by implementing the time out. The time out is intended to be the ultimate communication tool between members of the team before an irreversible and potentially life-changing mistake is made. What should the time out look like? The time out should be exactly that. Every member of the team should take time to focus attention on the patient. This is easier said than done. The immediate preoperative period is, by nature, a period when there are multiple tasks that must be accomplished to start a surgical procedure. The daily flow of a typical OR usually requires that these tasks take place efficiently in a relatively short period of time. This compressed time period leaves little opportunity for most team members to think about much other than their unique role in the upcoming case. Each member of the team is, by necessity, concentrating on their individual role and completing their responsibilities so the case can start. Because of the attention to the details that make up a surgical case, it's easy to lose focus on the "big picture." For years, the assumption has been that everyone knows what they're doing. The occurrence of wrong-site surgery disputes that assumption. In theory, almost everyone agrees that a "time out" before surgery is a good idea. The surgical time out, first widely implemented in 2001, is designed to take that last second look at the essentials of each case and assure that the right people are in place to do the correct procedure, on the correct patient, at the correct site. The elimination of wrong-site surgeries became a Joint Commission National Patient Safety goal in 2003, and in 2004, the Universal Protocol was introduced. The Universal Protocol provides three redundant checks to assure that the correct procedure is being performed.11 The first is the preprocedure verification and proper identification of the patient. The second step is marking of the operative site, and finally, the time out is performed immediately before surgery. If performed as intended, these steps will assure that the correct surgical procedure is performed. In practice, the time out isn't consistently performed and is often lacking at least one of the steps defined in a facilities policy. One study demonstrated only 60% adherence with established requirements following extensive staff and physician education.1 Although perioperative staff indicated that they felt the time out would improve patient safety and expressed willingness to undergo training, France and colleagues observed behaviors in surgery didn't support this.10 Failure to complete the time out process was properly implicated in a large number of surgical observations. Failures included performing the time out at the wrong time (that is, positioning the patient before the time out), making the incision before or during the time out, and failure to complete all elements correctly. In a study investigating surgical site marking and time out, Johnston et al. found the time out was performed after the incision in 19% of surgeries and not performed at all in 11% of the surgeries reviewed.12 Variances in how the time out is performed are very common. Although most hospitals and ambulatory surgery centers (ASCs) have well-thought-out policies and well-designed processes, these are meaningless unless the surgeons and staff understand their value and follow them consistently. Staff may interpret the time out policy and expectations according to their own understanding. What seems clear to one person may mean something very different to another. Clarity in writing the policy, along with education and implementation, can help mitigate the outcome when people read different things into it. Many ORs belong not just to a hospital, but to a hospital system. That makes it even more important to establish clear, unambiguous rules for the time out. If a surgeon sees the time out performed in one place, it's important for him or her to see the same process everywhere else throughout the system. Consistency in practice makes it easier to both understand and enforce the intent of the policy. Inconsistency not only decreases adherence, but it also degrades the importance. If there's a feeling among practitioners that the time out can be done anyway they choose, it lessens the impact and indicates that there's no real value in the time out. TJC and World Health Organization have defined essential elements of the time out, and most hospitals use these as a starting point for their time out policy. Many hospitals recognize the value of the last-minute review and have used the time out as an opportunity to address other issues to increase adherence to other measures, including the Surgical Care Improvement Project (SCIP). TJC requires, at a minimum, that correct patient identity, correct site, and procedure are confirmed during the time out.11 Many hospitals choose to include additional elements, including the following: * an accurate consent form that contains patient, witness, and surgeon signatures * correct patient position * relevant images properly labeled and correctly displayed * need to administer antibiotics * availability of necessary supplies and implants. TJC has also identified several other elements that make a time out effective. These include cessation of all other activities by all team members, full engagement of all team members, and verbal agreement by everyone involved in the procedure that the correct procedure is planned.13 While each institution creates its own policy regarding surgical site verification, the essential items should be present in all policies. When the time out occurs, the existing policy should be followed exactly every time. Studies have shown that in nearly half of observed time outs, the OR team doesn't follow the facility's policy.14 At the time designated in the policy, often immediately prior to the incision, all staff members in an OR, including surgeons, surgeon's assistants, anesthesia care providers, circulating nurses, and scrub persons, should cease all activity. Everyone involved turns their full attention to the time out. A designated team member leads the time out and includes all items as described in the policy. This leader speaks loudly enough to be heard by everyone. At least one team member should have primary source documentation in hand for comparison to the information provided in the time out. Each team member listens to the leader recite the items. Each person should verbally agree, again, loudly enough to be heard by all. Verbal agreement means that everyone understands and agrees with the information provided in the time out. At any point in the process, if a team member has questions, doubts, or disagreements with the items as stated, it's his or her duty to voice them. It's then incumbent upon the team to stop, resolve any questions to everyone's satisfaction, and begin the time out again. When there's a final agreement among the team members, the case can begin. Scenario II Ms. J, birth date 3/14/1951, saw a PA in early January with pain in both knees (right greater than left). Following several weeks of physical therapy, the pain was still present, so Ms. J scheduled another visit. This time, Ms. J saw an orthopedic surgeon at a satellite office. The surgeon examined the knee and felt that arthroscopy of the right knee was indicated. The surgeon directed his office staff to "schedule an arthroscopy," but the chart was at the downtown office, so the note wasn't entered in the patient record until the next day; a few days later, the case was scheduled. Ms. J reported to the hospital as ordered on February 28. The registration desk was busy, but the clerk took time to verify the date of birth on her armband (3/14/1961). The clerk removed the armband, corrected the birth date, and confirmed the date of birth with Ms. J. Once it was verified, the clerk placed the armband on and sent Ms. J to the prep area. The surgery schedule read "arthroscopy" without mention of which knee. The preoperative nurse asked Ms. J to have a seat while she paged the surgeon to obtain an order for the consent, which specified which knee would be operated on. The surgeon was running behind with his first case, so the PA stopped by the holding area to mark the correct knee before Ms. J was taken to the OR. She was medicated with midazolam in the holding area. When the PA asked if the left knee hurt, she responded yes, but because Ms. J had been medicated, the PA checked the history, physical, and the surgeon's order before marking the right knee. The circulating nurse took the patient to the OR, checked the consent, noted that it matched the procedure posted on the surgery schedule, positioned the patient, and prepped the knee that was marked. The surgeon scrubbed and came into the OR. When the circulating nurse reminded the surgeon it was time to do the time out, he said, "I'm already late enough," and asked for the scalpel. The surgical technologist, recognizing that the time out had not been completed, moved the scalpel to the back table and reminded the surgeon again that the time out must be completed before the scalpel could be handed off. After surgery, Ms. J was dressing to go home and said to the discharge nurse "Everything was great. I felt like everyone was really looking out for my best interests." REFERENCES 1. Clarke JR, Johnston J, Finley ED.Getting surgery right. Ann Surg. 2007;246(3):395-403. [Context Link] 2. The Joint Commission. National patient safety goals. 2013. http://www.jointcommission.org/standards_information/npsgs.aspx. [Context Link] 3. Feldman D.The inside of a time out morbidity and mortality rounds on the web. 2009. http://www.webmm.ahrq.gov/case.aspx. [Context Link] 4. O'Reilly KB.Wrong surgeries a product of poor communication. (2009). http://www.ama-assn.org/amednews/2009/12/07/prsf1211.htm. [Context Link] 5. Seiden SC, Barach P.Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable. Arch Surg. 2006;141(9):931-939. [Context Link] 6. Mulloy D, Hughes RG.Wrong Site Surgery: A Preventable Medical Error. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008:chap 36. [Context Link] 7. World Health Organization. Patient Safety. http://www.who.int/patientsafety/safesurgery/tools_resources. [Context Link] 8. 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Altpeter T, Luckhardt K, Lewis JN, Harken AH, Polk HC.Expanded surgical time out: a key to real-time data collection and quality improvement. J Am Coll Surg. 2007;204(4):527-532. 14. OR Manager "OR's Vary in How They Do the Time Out, and many Don't Follow Their Own Policy" OR Manager. 2008;24(3): 1, 9-10