Tuesday, March 29, 2016

"Errors upstream and downstream to the universal protocol associated with wrong surgery events"

           "Errors upstream and downstream to the universal protocol associated with wrong surgery events". The recent review of the Veterans Health Administration experience with wrong surgery by Paull et al provides much insight into the persistent problem faced nationally with adverse events. The premise of the study was that “the Universal Protocol has been associated with prevention of wrong surgery procedures; however, such events still occur”. In their study, of 308 RCA reports of wrong surgery events, 48 (16%) would have occurred despite adherence to the universal Protocol and a well-performed time out. Their conclusion was that “future prevention of wrong surgery events will require diligence upstream and downstream from the UP, the participation and communication between multiple stakeholders, and application of new technologies and procedures”. Paull DE, et al Am Jnl Surgery July 2015
        Following the announcement of this publication we held a discussion with several spine surgeons on this very topic. They relayed to me that the natural assumption today is that when wrong level spine surgery events occur, there was willful violation of known precautions. They reiterated that, in fact, this does not seem to be the case in most instances at this point in time. Their opinion is that by now, in most cases, the universal protocol was likely followed and fixed intraoperative markers were used. In the majority of cases it appears that one or more of the circumstances were likely contributing factors (see below).
The group’s recommendations were fairly straight-forwards:
A. Education to assure everyone is aware that in spite of following protocols, mistakes are still possible due to:
1.    Distraction, Fatigue
2.    Routineness of procedure: Complacency
3.    Communication problems including handoff
4.    Equipment or Staff problems during localization.
5.    Patient characteristics: body habitus, spinal deformities, vertebral morphological variant.
6.    Confirmation Bias: accepting of Inadequate views due to positioning in lieu of alternate / additional imaging or secondary confirmation with additional expert
B. Recommendation that:
1.    Repeat localization images if the incision is changed, the patient is moved or the retractors are moved.
2.    Assure preoperative and intraoperative images are visible to ALL team members.
3.    Routine use of second surgeon / Radiologist who assesses the validity of the level in difficult cases as noted above at a minimum and if possible in all cases (need change in technology so that the radiologist can see the image and see what the surgeon sees).
4.    Establish sterile cockpit and absolute concentration w/ no distractions during crucial stages.

In my conversation it was clear that creation of lengthy policies and checklists that do not pertain to a particular institution may likely create bigger problems rather than solve them. It is apparent that many surgeons have come to grips with the fact that no single solution will solve this problem. They acknowledge that utilization of team training, which includes education in human factors and communication, is one of many steps which will ultimately lead to virtual elimination of adverse events. Having said that, the majority of the surgeons conceded that longevity of this training is likely only if the institution utilizes training, policies and checklists designed to fit local needs and personalities. They felt that single episode / one-sized-fits all training is unlikely to have lasting effects as it may not touch the heart and soul of the team. In addition, they were crystal clear that institutional leadership must be aware of the upstream and downstream interferences as noted in the article by Paull et al. They expressed concerns that institutional focus on the surgical team involved in an adverse event, while ignoring systemic issues, will ultimately lead to loss of motivation and subsequent burnout. Clearly as an institution, the healthcare industry has a way to go to reach this goal, but it is a goal within our grasp.

Kenneth A. Lipshy, MD, FACS

1.    Paull DE,et al Errors upstream and downstream to the universal protocol associated with wrong surgery events in the veterans health administration. AM J Surg, 2015;210:6-13.

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