Your Patient Safety Survival Guide
Page 8
Doctors and nurses wash their hands less than half the times required. In the hustle and bustle of delivering care, it is easy to have a momentary lapse. Even the best providers need reminders to wash their hands. It is important that all providers (and visitors) wash their hands every time they enter or exit a patient room—everyone must wash on the way in, and wash on the way out.
We are all part of the healthcare team. Don’t be afraid to remind your healthcare providers and visitors to wash their hands when you don’t see it happen with your own eyes. Speaking up for safety is not about challenging our providers, it is about helping them. By working together, we can prevent people from picking up harmful and potentially deadly hospital infections.
In the hospital and other healthcare settings, it’s okay to ask everyone to wash their hands on the way in and out of patient rooms. Everyone must “wash in” and “wash out,” and most people need help remembering to do so.
Information for Providers
More than one out of every twenty-five US hospital patients is dealing with a healthcare-associated infection on any given day. Proper handwashing is the single most effective way to stop the spread of these infections.
Without realizing it, we all go through our lives making a constant string of mistakes; however, we barely notice most of them because the spell-check factor kicks in: We don’t register all the times we make what could become a significant mistake. For example, the moment we decide not to wash our hands never immediately kills anybody, but millions of such moments kill patients every day. Because such minor mistakes rarely lead to a bad outcome, we lose the necessary feedback to motivate us to improve.
To overcome the spell-check factor, we need frequent reminders to wash hands every time we enter and exit a patient room. Patients can help us remember to “wash in” and “wash out.” However, we must actively encourage patients to do so and respond approvingly when they do.
Table 3.2.
Patient Action Plan
Healthcare-Associated Infections
TIMING
PATIENT ACTION
✓
Before going to the hospital
I realize that I can help reduce the chance of getting a dangerous infection from the hospital.
I know why healthcare providers should wash their hands every time they enter and exit my room or examine me.
I understand how easy it is for hospital staff to forget to wash their hands.
I am ready to observe whether people wash their hands when they enter and leave my hospital room.
I practiced what to say if doctors, nurses, or anybody else forgets to wash their hands.
I explained to family and friends who will be involved in my care that speaking up is not about challenging healthcare professionals, it’s about helping to keep all of us safe.
I know I can keep a bottle of hand sanitizer in my hospital room to remind myself and others about proper handwashing.
While I am in the hospital and able to do so
I will remind my visitors to wash their hands when they enter and leave my room—to “wash in” and “wash out.”
I will ask healthcare providers to wash their hands when I don’t see it happen with my own eyes.
I might keep a bottle of hand sanitizer on my tray table as a helpful reminder.
Table 3.3.
What You Can Say
When Someone Walks into a Patient Room without Washing Hands
Sticky Message: Wash In, Wash Out
Patient Request
Desired Response
“Sorry, I didn’t see you wash your hands. I know it’s important and I’d really appreciate you doing this for everyone’s benefit.”
Staff: “I just washed my hands before coming in, but I am happy to do it again for you to see. Thank you for speaking up.”
“Hi, I’m so glad you’re here. To make sure I don’t pick up an infection, everybody needs to clean their hands before they come in my room. Do you mind washing yours?”
Visitor: “Oh, sure, no problem.”
“Gee, I didn’t see you wash your hands. I know you’re busy, but I don’t want anybody to pick up an infection. I’d feel better if I saw you wash your hands.”
Staff or Visitor: Of course. Thank you for reminding me. It’s people like you who keep us all safe.”
Chapter 4
Oops!
Eliminate Mistakes during Surgery and Other Procedures
Removal of the Wrong Testicle
Benjamin Houghton had undergone successful treatment for testicular cancer. However, the treatment led to painful tissue damage. Being in his forties and the father of four, Mr. Houghton was scheduled for surgery to remove the painful testicle and elected to have a vasectomy on the other testicle. The hospital rescheduled the surgery several times. The day the surgery was finally performed, the usual consent form was presented. However, Mr. Houghton was reluctant to sign the form because he could not read the consent without his glasses. The staff assured him that it was the same form he had signed previously. In reality, the updated form had been completed improperly. The new consent form indicated that the right testicle was to be removed instead of the left. In accordance with the unverified (and incorrect) consent form, the wrong testicle was removed. As a result of his only healthy testicle being removed, Mr. Houghton was left with a choice between lifelong drug treatment that included serious risk for cancer and heart disease or a life without the drugs that would leave him with an inability for normal sexual functioning and risks for osteoporosis, broken bones, fatigue, memory loss, weight gain, loss of muscles strength, and depression.1
The Nature (and Name) of the Beast
Mr. Houghton’s experience of having the wrong testicle removed is a classic example of what medical literature describes as a wrong-site surgery and what this book refers to as an off-the-mark procedure. The two terms refer to exactly the same type of events, but the Joint Commission’s term is confusing because it leads people to think that this category of events only pertains to surgeries. That is simply not the case.
The original term also led many to think of wrong-site surgeries as wrong-side surgeries. This sound-alike/look-alike problem has contributed to healthcare professionals overlooking events that involved the correct side of the body but the wrong location (e.g., correct arm but wrong location on the arm; correct hand, but wrong finger; etc.). The term has also caused some to overlook events involving the wrong patient or procedure. Although there has been a great deal of misunderstanding stemming from the original label choice, its definitional criteria are quite clear. As indicated in the table below, a wrong-site surgery/off-the-mark procedure includes any invasive procedure, including, but not limited to, surgery, which involves one of the four Ps: wrong patient, procedure, part, or place.
Table 4.1.
What Counts as an Off-the-Mark Procedure
Type of Services
Skin penetration through incision or needle
Fluid or substance injected into
a joint or body space
Aspiration of body fluid or removal of body tissue
Insertion of an instrument into a body opening or cavity
Surgery
Type of Error
Wrong patient
Wrong procedure—other than indicated or intended (even if the procedure helped)
Wrong body part (site)—symmetrical body parts such as legs, arms, feet
Wrong body place or spot (site)—such as a bone’s front vs. back, middle vs. end
No Exceptions
Any degree of harm, including the absence of notable harm to the patient
Any type of facility—hospital, nursing home, outpatient surgery center, etc.
Any type of provider—physician, nurse, technician, etc.
An off-the-mark procedure refers to the same category of event as a wrong-site surgery, and it includes the exact same criteria set forth by the Joint Commission. The term off-the-mark procedure is offered as a substitute because the original term has contributed to widespread confusion about what constitutes an event.
Furthermore, off-the-mark procedure criteria apply regardless of where the event occurs, who performs the procedure, and the degree of harm to a patient, including the absence of harm. For example, if a lab technician drew blood from the wrong patient and this did not result in harm to anybody, the incident would still count as a wrong-site surgery/off-the-mark procedure. There are numerous reasons for tracking all such events regardless of the degree of harm, as will be explained later in this chapter.
Things That Should Never Happen
In the minds of most people, wrong patient, wrong part, wrong place, and wrong procedure mix-ups should never happen.2 Indeed, the National Quality Forum includes this category of event among its list of what it literally calls never events, referring to, as the name implies, a healthcare behavior or patient outcome that should never occur.3 The reason that off-the-mark procedures should never happen is they carry a high probability of a devastating outcome and are largely, if not completely, preventable. Well-publicized cases make clear why off-the-mark procedures are thought of as disturbing events that should never happen. They potentially signal that larger systemic problems exist. Consider these illustrative cases.
Wrong Leg Amputation: The Willie King Case
The widely publicized case of Willie King unleashed a flood of previously unreported off-the-mark procedures and drew modern medicine’s attention to this category of events. The fifty-two-year-old Mr. King was admitted to University Community Hospital in Tampa, Florida, to have his leg amputated. During the procedure, the wrong leg was removed. By the time the surgeons realized their mistake, it was too late to reverse the damage caused, and the leg had to be removed. The attending surgeon was fined $10,000, and his medical license was revoked for six months. The hospital paid Mr. King $900,000, and the surgeon personally paid him another $250,000. The hospital admitted that a chain of errors culminated in the wrong leg being prepped for the surgery.4
Wrong Embryo Implant: The Susan Buchweiz Case
In a more recent case with a more complex outcome, a Californian by the name of Susan Buchweiz was awarded $1 million in damages to settle a malpractice lawsuit against a fertility specialist who accidentally implanted her with the wrong embryos and hid the mistake until her baby was ten months old. But the tragedy did not end there. The embryos Susan Buchweiz received were intended for a married couple that underwent in-vitro fertilization on the same day using the husband’s sperm and a different egg donor. The sperm donor was subsequently granted temporary visitation rights, forcing coparenting among unfamiliar people. Later, the sperm donor and his wife sued for custody of the three-year-old child that Buchweiz had raised since birth.5
Wrong Sperm Insemination: The Baby Jessica Case
A fertility clinic in New York impregnated Nancy Andrews with the sperm of a complete stranger rather than the sperm of her husband. Instead of giving birth to a child that resembled both of her Caucasian parents, she delivered Baby Jessica who was significantly darker skinned. Subsequent DNA testing revealed that Baby Jessica’s biological father was of African American descent. Although the Andrews have kept Jessica and are raising her as their own, the couple has filed a medical malpractice suit against the fertility clinic and against the embryologist who reportedly mistakenly switched the samples.6
Wrong Organ Transplants: The Jésica Santillán Case
Seventeen-year-old Jésica Santillán awaited and was finally scheduled to receive the heart and lungs of a patient whose blood type matched hers. When the organs arrived, Jésica’s physicians and surgical team failed to check that the blood types actually matched. They did not. As soon as the incompatible match between blood types was noticed, the hospital acknowledged the error to Jésica’s family, admitted that simple errors contributed to the mistake, and committed to learning from this horrible incident. Through concerted effort and extraordinary means, the hospital was able to quickly obtain a second set of organs for Jésica. But it was too late. Complications arose as surgeons attempted to replace the initial transplanted organs with the second set of organs. Jésica was left in a comalike state and pronounced brain dead soon thereafter. The hospital reached an agreement on an undisclosed settlement with the family, which prohibits the hospital and family from commenting further on the case.7
Admittedly, the experiences in Mr. Houghton’s and these other cases probably represent some of the most horrifying examples of off-the-mark procedures; not all events in this category end with such a devastating impact. However, more than perhaps any other type of medical mistake, off-the-mark procedures are likely to harm both the patient and his or her providers. Even in the cases of minimal or no physical harm to patients, they often precipitate a loss of trust on the part of the patient and a loss of confidence on the part of the providers.
Minor Mix-Ups Beget Major Screw-Ups
If you wonder how a major or invasive procedure can go so terribly wrong, imagine this: a surgeon approaches the start of his day with the mindset that he has three big procedures that he has specifically planned and prepared for and a few mundane surgeries to perform. He goes through the usual routine of confirming with patients the procedures to be performed, including verification of the proper site of their operations. But then—as so often happens—there are a few snafus. Among other things, due to an overflow of cases and scheduling pressures, the patient on whom he will ultimately perform the wrong surgery—his last patient of the day—gets reassigned to a different operating room with a different surgical team. This means that the nurse who had performed the preoperative brief with the surgeon is no longer on the case. Instead, a new team is assembled to assist the surgeon. The surgery is completed successfully. However, fifteen minutes later, while dictating the operation report, the surgeon realizes he performed the wrong procedure on his last patient.
This case really happened. The surgeon immediately apologized to the patient. Although the surgeon convinced the patient to allow him to take her back into surgery to perform the correct procedure, she would not see him for follow-up care. According to her son, she had lost confidence in the surgeon. Having been emotionally traumatized by the experience, the surgeon, David Ring of Massachusetts General Hospital, felt compelled to shed more light on the problem of off-the-mark procedures. In 2010, he published an account of his unfortunate case in the New England Journal of Medicine.8 Dr. Ring’s write-up represents one of the rare instances in which a physician elected to publicly disclose his error before any press scrutiny or impending media attention.
As noted by surgeon John Clarke of Drexel University, off-the-mark procedures don’t “just happen.” However, minor mix-ups happen all the time, and it is precisely th
ese errors that set the stage for major screw-ups. Scheduling errors are notorious for contributing to major downstream mistakes. Case in point: during the course of writing this chapter, a medical office assistant attempted to schedule me for a left knee MRI rather than a right knee MRI, which might have been understandable given that I was having issues on both sides of my body. I caught and corrected the error—or so I thought. Apparently, the office assistant’s notes were confusing. When someone subsequently called from the MRI office to confirm my appointment, she had listed me for an MRI of both knees. Even if both knees had been subjected to this unnecessary diagnostic procedure, it would not have been such a terrible thing. And I could have easily assumed that the surgeon changed his mind and decided after my office visit to order an MRI of both knees—either for comparison purposes or because I had also been experiencing minor difficulty with my left knee. But this is the very sort of mix-up that could easily have contributed to a surgery on a healthy knee. That would have been a big deal! Interestingly, when I went to my first postsurgical physical therapy appointment, the clinician assigned to my case was also confused about which knee had been operated on, at first treating the wrong leg. Clearly, the initial error had lived on.
Here is another example of how easily an off-the-mark procedure might occur. Imagine that a nurse marks a left leg with an “L” to indicate the location for the preoperative injection of dye while another nurse marks the same leg with an “L” in a different spot to indicate where the surgery is to occur. If the surgeon only sees one marking, he or she could easily operate on the wrong area of the leg. Or, thinking back to Mr. Houghton’s case, somebody could easily take the consent verification process for granted and mistakenly direct the surgeon to operate on the wrong side of the body. Such mix-ups happen too frequently.