________________________________________________ Medical Error Prevention and Root Cause Analysis
WRONG-SITE SURGERY Operating on the wrong part of a patient’s body is an obvious sign that there is a problem in the operating room system. Interestingly, wrong-site surgery occurred more commonly in orthopedic procedures than in all other surgical specialties combined. The American Academy of Orthopaedic Surgeons takes this issue seriously, and it has taken special steps to eliminate the problem. For example, it recommends that a surgeon sign their initials at the correct site of surgery with an indelible pen. Unless the initials are visible, the surgeon should not make an incision [12]. Writing “NO” in large black letters on the side not to be operated on was suggested in the past, but this is discouraged due to possible confusion with the surgeon’s initials. In spinal surgery, the Academy recommends that an intraoperative radiograph and radiopaque marker be used to determine the exact vertebral level of spinal surgery [12]. Whatever the mechanism used to prevent and reduce the incidence of this error, it is clear that this is not just the surgeon’s problem. All operating room personnel, including physicians, nurses, technicians, anesthesiologists, and other preoperative allied health personnel, should monitor proce- dures to ensure verification procedures are followed, especially for high-risk procedures. Due to the prevalence of wrong-site, wrong-procedure, and wrong-person surgeries, the Joint Commission, along with more than 50 professional healthcare organizations, convened two summits to help reduce the occurrence of these errors. The first summit, convened in 2003, developed a Universal Protocol that consisted of the following: a preprocedure veri- fication process; marking the operative/procedure site with an indelible marker; taking a “time-out” with all team members immediately before starting the procedure; and adaptation of the requirements to all procedure settings, including bedside procedures. However, the incidence of wrong-site surgeries continued to increase, and in 2007 and 2010, additional sum- mits were organized to pinpoint barriers in compliance and discover new strategies to eliminate these errors [14]. As of 2019, the Universal Protocol has been incorporated into the National Patient Safety Goal chapter of the Joint Commission accreditation manual [15]. PATIENT SUICIDE It is estimated that between 48 and 65 hospital inpatient suicides occur per year in the United States. Most of these cases (31 to 52) occur in psychiatric units or involve psychiatric inpatients. The most common method is hanging [50]. Times of care transition are particularly risky, with a 200% increase in risk in the week after discharge from a psychiatric facility; the elevated risk continues for four years [18]. Other risk fac- tors include previous suicide attempt or self-injury, mental or emotional disorders, history of trauma or loss, serious illness or chronic pain, substance use disorder, social isolation, and access to lethal means.
The most common root cause documented for patient suicide reported between 2010 and 2014 was shortcomings in assess- ment, most commonly psychiatric assessment [18]. In addition, nearly 25% of behavioral health facilities accredited by the Joint Commission were found noncompliant with the requirement to conduct an adequate suicide risk assessment in 2014. The Joint Commission has recommended a number of suicide risk reduction strategies, including [18]: • Review each patient’s personal and family medical history for suicide risk factors. • Screen all patients for suicide ideation, using a brief, standardized, evidence-based screening tool. • Review screening questionnaires before the patient leaves the appointment or is discharged. • Establish a collaborative, ongoing, and systematic assessment and treatment process with the patient involving the patient’s other providers, family, and friends, as appropriate. • To improve outcomes for at-risk patients, develop treatment and discharge plans that directly target suicidality. • Educate all staff in patient care settings about how to identify and respond to patients with suicide ideation. • Document decisions regarding the care and referral of patients with suicide risk. A simple review of these measures demonstrates that healthcare providers can avoid the devastating impact of an inpatient suicide by implementing routine preventative strategies, such as removing harmful items and careful screening through the admission and discharge processes.
OPERATIVE AND POSTOPERATIVE COMPLICATIONS
Many of the sentinel events reported to the Joint Commission regarding operative and postoperative complications occurred in relation to nonemergent procedures, such as interventional imaging and/or endoscopy, tube or catheter insertion, open abdominal surgery, head and neck surgery, orthopedic sur- gery, and thoracic surgery [17]. The majority of the reporting healthcare facilities cited miscommunication as the primary root cause. Other identified causes include failure to follow established procedures, incomplete preoperative assessment, inconsistent postoperative monitoring procedures, and failure to question inappropriate orders. In order to reduce the risk, reporting facilities have identified a number of strategies, including improving staff orientation and training, increas- ing educational opportunities for physicians, clearly defining expected channels of communication, and monitoring con- sistency of compliance with procedures. Healthcare facilities should review postoperative patient monitoring procedures to ensure an adequate level appropriate to the needs of the patient, regardless of the setting (e.g., operating room, endos-
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