Wrong-Site Surgeries: How to End the Tragedy? Essay

In 2003, as an outcome of all the sentinel events reported to the Joint commission lead to the creation of the “The Universal protocol for preventing wrong site, wrong procedures, and wrong person surgery” (Mulloy & Hughes 2008). So, one of the ways that could have potentially prevented the situation from happening at the first place was implementing the universal protocol procedure. According to the protocol the conduction of proper pre as well as post-operating procedures are extremely mandatory. Therefore, by enforcing a standardized routine pre-operating procedure such as verifying the patient as well as the correct site for the procedure, by having the medical staff or preferably the physician marking the operating site with his or her initials before the surgery will be an effective preventive measure (Mulloy & Hughes 2008).

It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

With all of the possible problems that could occur during surgery, a wrong-site, wrong-patient mistake is one that should never arise. Nightingale Community Hospital (NCH) fully understands the importance of doing away with these errors and has set up protocol to work towards this goal. While the protocol is in place, it is not fully compliant with Joint Commission (JC) standards.

This quality improvement discussion will review the purpose of quality management in health care industry and why it is needed. Included in this QI report will be an explanation of the

Each year medical errors cause more than 400,000 American deaths and at least 10-20 times that number experience serious harm. Researchers say that is equivalent to “three 747 airplanes crashing each day.” Medical errors rank as the third-leading cause of death in America. Therefore, patient safety is a national concern.

My experience in both my previous career in nursing and human resources has dealt with approaches in quality improvement in patient safety and different metrics in the turning up organizational behavior as well as up swinging the operations of the organizations respectively. We live in a rapidly changing world, and healthcare industry is not exempted from it. Because I will be playing an indispensable role in the future, I am very interested on the concept of quality improvement and what not and identify possible future challenges and draw lessons from healthcare organizations that has spearhead innovative changes to providing healthcare by pursuing the triple dimensions of the improvement of healthcare in general that is Improving the patient experience of care (including quality and satisfaction); Enriching the health of populations; and Reducing the per capita cost of health care.

Clinical human factors are important in optimising patient safety, having complete understanding reduces the risk of unintentional mistakes. This scientific discipline must be followed by each individual healthcare professional. Having an understanding off these skills strengthens performance meaning safer surroundings and more comfortable experiences for patients; being the forefront of patient care. An example of poor understanding in human clinical factors be the case study of Elaine Bromiley, 2005 resulting in death. Elaine attended routine sinus surgery, during this a sequence of occurrences caused by lack of communication, teamwork and management equalled Elaine’s passing. This case emphasises in

Health care professionals have multiple responsibilities and one among them is ability to transfer patient information or handoff to another healthcare provider. Clear and accurate handoff communication between healthcare providers of operating room team is an integral part to patient safety. Exchange of patient information occurs many times a day and are vulnerable to communication errors that may negatively impact patient safety. In fact, poor communication is one of the reported cause of sentinel events within United States hospitals and is at high risk often among surgical patients than in any other clinical specialty. Surgical patients move from perioperative to intraoperative to post-operative areas and transition between these specific points requires effective communication. Rapid turnovers are most often vulnerable to communication errors that could lead to fatal implications.

Errors pervade in our lives whether it is our home, in our workplace, or in our society. The effects of healthcare errors have impacted all our lives either directly or indirectly. Patient safety and quality care are at the core of healthcare system which strongly depends upon nurses. “To achieve goals in patient safety and quality, thereby improve healthcare, nurses must assume the leadership role. Nurses need to ensure that they and other healthcare providers center healthcare on patients and their families. Even though the quality and safety of healthcare is heavily influenced by the complex nature

Wrong site, wrong procedure, and wrong patient errors are avoidable safety issues. Nearly 1.9 trillion dollars are spent on medical errors each year in the United States (Catalano & Fickenscher, 2008). Between 1995 and 2007, 691 wrong-site surgeries have been reported to The Joint Commission's Sentinel Event data repository (AHC Media LLC, 2008). In 2003 in response to the outcry for better patient safety The Joint Commission

One problem that has plagued the medical field is the issue of “wrong surgery.” The article Electronically Mediated Time-out Initiative to Reduce the Occurrence of Wrong Surgery discusses the prevalence of wrong surgery, heavily emphasizing that the main concern surrounding this topic is the frequency in which the circumstances that comprise the issue occur. These problems include performing surgery on the wrong person, performing the wrong type of surgery, and performing the surgery on the wrong location.

The World Health Organisation (WHO) implemented the surgical safety checklist, to minimise the discrepancies that occur as a result of improper identification of the patient (appendix O post 3). Improper identification leads to wrong procedure, hence complication and possibly death (Position Statement Surgical Safety 2015). The WHO checklist helps to improve surgical safety through confirming safety practices are upheld and developing better communication within the multidisciplinary team (Position Statement Surgical Safety 2015), thus providing optimum patient care (ACORN Competency standard 5). Surgery related complication and mortality was reduce by 33%, through a study of eight hospitals from 2007 to 2008 (Position Statement Surgical Safety 2015). Therefore proving that compliance with safety measure were increased as a result of endorsing the SSC, and obliges to competency standard 3.3. Through briefing and debriefing, standard of care is improved, as the whole multidisciplinary team is made aware of the procedure, and allows for optimal performance, which decrease surgery time, thus improve surgical safety (ACORN Competency Standard 9). Furthermore it is important that each hospital adapt their own policy in regards to the type of facility, such as in the occurrence of near miss episode (appendix 1,), institutions must refine their policy to provide the best care for the patients (Position Statement Surgical Safety 2015).

In today's modern world with plenty of technology, it is hard to believe that we cannot figure out how to reduce Medical errors. The issue of medical error is not new in health care organizations. It has been in spot light since 1990's, when government did research on sudden increase in number of death in the hospitals. According to Lester, H., & Tritter, J. (2001), "Medical error is an actual or potential serious lapse in the standard of care provided to a patient, or harm caused to a patient through the performance of a health service or health care professional." Medical errors

The concern with not educating trainees before graduation is that incident and near misses tend to remain underreported because of the perpetuating negative culture surrounding error reporting. This in turn hinders learning from the event and stifles growth toward voluntary sharing of broken processes and system failures (Barnsteiner, 2011). The current focus on Quality Improvement is to provide high reliable care with little to zero risks by including the “combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make changes that will lead to better patient outcomes (health), better system performance (care) and better professional development” (IHI, 2015).