tapping into our toolbox: wrong-site surgery prevention...
TRANSCRIPT
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November 17, 2015
Tapping Into Our Toolbox: Wrong-Site Surgery Prevention Tools
Presenter
• Manager, Clinical Analysis
• Led collaborative projects focusing on the prevention of wrong-site surgery.
– Three-year initiative with the Pennsylvania Partnership for Patients Hospital Engagement Network.
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Objectives
• Identify wrong-site surgery (WSS) prevention tools and resources available on the Authority's website
– Self- Assessment Checklist for Program Elements
– Observational Monitoring Tool
– Wrong-Site Surgery Error Analysis Form
• Explain how the Gap Analysis and Action Plan to Prevent Wrong-Site Surgery can be used to identify practice gaps.
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Authority Website
www.patientsafetyauthority.org
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• Place mouse pointer over “Educational Tools”
• Click on “Patient Safety Tools”
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Accessing the WSS Toolkit
• Click “Preventing Wrong-Site Surgery” in the list of patient safety tools
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WSS Toolkit
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WSS Toolkit (con’t)
• “Program Tools”
– Self-Assessment Checklist for Program Elements
• Surgery and anesthesia
– Observational Monitoring Tool
• Surgery and anesthesia
– WSS Error Analysis Form
• Wrong ureter
• Wrong spinal level
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WSS Toolkit (cont’d)
• The toolkit also contains:
– Educational tools
– Snapshots
– Advisory articles
– Other publications
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Self-Assessment Checklist (SAC) for Program Elements
Finding the WSS SAC Tool
• Two SAC tools
– Surgery
– Anesthesia
• Regional and local blocks
• Electronic or handwritten entry
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Self-Assessment Checklist (SAC)
• Evaluates operating room policies and procedures for the following:
– Scheduling
– Consent
– Preoperative Verification
– Site Marking
– Time-Out
– Specimen Collection
– Upon Completion of Procedure
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Sample Section - SAC
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SAC - Anesthesia
• Evaluates anesthesia block policies and procedures for the following:
– Consent
– Preoperative Verification
– Site Marking
– Time-Out
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Observational Monitoring Tool (OMT)
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Finding the OMT
• Two observational tools – Surgery
– Anesthesia • Regional and
local blocks
• Electronic or handwritten entry
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Observational Monitoring Tool (OMT)
• Monitor compliance of policies and procedures in the following:
– Scheduling/Consent
– Preoperative Verification
– Site Marking
– Time-Out
– OR Turnover
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Sample Section - OMT
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OMT - Anesthesia
• Monitor compliance with anesthesia policies and procedures for the following:
– Scheduling/Consent
– Preoperative Verification
– Site Marking
– Time-Out
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WSS Error Analysis Form
Finding the WSS Error Analysis Forms
• Three forms
– Main
– Ureter
– Spinal level
• Electronic or handwritten entry
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WSS Error Analysis Forms (con’t)
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WSS Error Analysis Forms (con’t)
• Captures information about WSS near misses and actual occurrences
• Aids in the analysis of actual WSS events and near misses
• Asks specific questions to evaluate ureter and spinal level-related procedure errors
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WSS Error Analysis Forms (con’t) Categories: • Extent and type of error
• Patient Characteristics
• Scheduling
• OR Consent Documentation
• Preoperative Verification
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Questions: • Why do you think the WSS occurred?
• According to investigation, what were the actions taken to prevent the error from harming this patient?
Categories: • Marking the Operative Site
• Time-Out
• Intraoperative Specimen Handling
• Communication Issues/Culture
Gap Analysis and Action Plan to Prevent Wrong- Site Surgery
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Finding the Gap Analysis Tool
• Identify potential practice gaps
• Electronic or handwritten entry
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Gap Analysis Tool
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• Compare observations to the Authority’s 21 Principles* following 5 phases: – Before the patient arrives on the day of surgery
– In the preoperative holding area
– In the operating room
– In the operating room immediately before the procedure
– Notify radiology for site confirmation • Spinal procedures
*http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/PWSS/Pages/principles.aspx
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Gap Analysis Tool (con’t)
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• Compare observations to
– 21 principles
– Goals of Principles
– Measurement Standard(s)
• Develop action plan
• Identify barriers to compliance
Surgeon Office Tools
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Finding the Surgeon Office Tools
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Surgeon Office Tools
• For Surgeon Offices: What You Can Do to Prevent Wrong-Site Surgery – Tip card and checklist help to identify of the patient’s
record to address and reconcile with the surgeon.
• Monitoring of Preoperative Information from Surgeon’s Office Available at First Encounter
– Monitor 10 cases to help ensure the availability of relevant preoperative information during preadmission testing or preoperative admission.
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Website demo
Questions?
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Thank You!
www.patientsafetyauthority.org
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