In this case, the error was caught in time. A patient scheduled for eye surgery at The Miriam Hospital on June 11 had the wrong eye anesthetized, but the mistake was discovered before entering the operating room.
A month earlier, a cleft-palate surgery at Hasbro Children’s Hospital had gone a bit farther before the wrong-side error was caught. Four other wrong-site surgeries have occurred in the state just since 2007, including a wrong-knee arthroscopic surgery.
Mind you, thousands of surgeries are safely completed in Rhode Island each year, at hospitals, in ambulatory surgical centers and in doctors’ and dentists’ offices. Locally and nationally, the error rates are still small when compared with, say, medication errors or other problems.
But every month, The Joint Commission says, eight to 10 new cases of wrong-site, wrong-procedure and wrong-person surgeries are reported across the nation. It’s the most common kind of “sentinel” event logged by the agency – which requires facilities to report unexpected occurrences involving death or serious physical or psychological injury.
Five years ago, The Joint Commission released a recommended protocol to improve safety, but the incidence of errors has continued to increase. So the agency has kept refining and promoting its protocol, urging patients to advocate for themselves as well.
Now Rhode Island’s hospitals are collaborating to eliminate (or at least minimize) these errors by standardizing their safety procedures so every operating room in the state has the same checklist, the same way of verifying surgical sites, and the same pre-surgery “time out.”
The goal, hospital leaders say, is to not only adopt the best practices recommended by The Joint Commission, the World Health Organization and other experts, but also to leverage the experience and wisdom of surgical teams across the state so they can learn from one another.
And because Rhode Island is so small, and many surgeons have privileges at multiple hospitals and may also work in stand-alone facilities, they say, having a unified surgical protocol will also help improve quality and safety just by standardizing procedures.
“We, working together, are really trying to make Rhode Island a leader in this,” said Dr. Kathleen C. Hittner, president and CEO of The Miriam Hospital and chair of the Hospital Association of Rhode Island board of trustees.
“I don’t think we’ll ever be able to totally prevent” these incidents, she added. “Nothing is completely error-free. But to be able to minimize the chance that this can ever happen to somebody – I think that everyone working together and really raising this to a new level of importance really helps us to accomplish these goals.”
The protocol is built on the notion that surgeries are conducted by a team, and the surgeon is that team’s leader. It uses a checklist to guide the entire process, and it actively involves the surgeon at key points:
• The surgeon and a second licensed provider – a nurse, anesthesiologist or other team member – verify the site, confirming it with the patient, who isn’t sedated until after the site has been confirmed.
• The surgeon personally marks the site to be operated on, and initials it.
• Before the surgery begins, the surgeon calls a “time out,” a practice that has been in place for awhile at many hospitals, but is typically led by a nurse.
Jean Marie Rocha, vice president of clinical affairs at the Hospital Association, said the protocol has been in the works for about a year, with extensive hands-on involvement from administrators and surgical teams from The Miriam, Rhode Island Hospital, the Providence VA Medical Center, Kent Hospital, South County Hospital and two ambulatory centers, Blackstone Valley Surgicare and Wayland Square Surgicare.
The survey found substantial variations, Rocha said, which in itself is a problem. But rather than just impose a new protocol on all of them, the group worked with surgeons, nurses and other team members to get their input, so the final product combines national and international standards with the insights of local professionals.
In late June, the Hospital Association hosted a statewide educational event for surgical teams to learn about the new protocol, and many of the hospitals have put together educational packets for their staff, Rocha said. All are providing training and will continue to do so.
“The educational piece is paramount to the protocol’s success or failure,” she said.
The main issue going forward will be continued training and monitoring, Kent Hospital President and CEO Sandra Coletta added, but everyone is eager to improve safety, because everyone is aware of the risks.
“Quite honestly, no one is immune to these events,” she said. “This is not something that happens to just one surgeon or one hospital. This is something that happens across the country, and God forbid, it can happen to anybody at any time. … So getting the buy-in and support for trying to prevent the events is not at all difficult.” •
