Now, I want you to see something that is so illustrative of the very points Tom Botts makes below. What follows is an email from one of our best surgeons to his Chief making suggestions on how to avoid the kind of wrong-side surgery we recently had. This surgeon is a wonderful person as well as a fine clinician, and his intentions are noble and thoughtful.
But, read the email and compare it point-to-point with the lessons learned by Tom. I don't in any way mean to be disrespectful of the surgeon's thoughts or efforts, but I have become sensitized to the fact that good intentions can lead us into several organizational and learning traps. This is no reflection on him personally: We are all learning a lot about how teams function and can improve in high-stress and unpredictable environments. This area of expertise is not usually part of our training, whether we studied medicine, economics, history, or art. So, we have to learn it now, on the job.
See how many organizational and learning traps you can detect in this note. At the end, I'll give you a couple that I noticed. See if you agree with mine, and please add your own comments.
I've given some thought to the issue of wrong-side surgery since you presented the matter at last week's meeting, and I have some suggestions. I believe we can strengthen our approach to the problem with only modest extra effort in the OR. I would consider the following changes:
1. "Time Out" is now an oral exercise. I'd add written confirmation. Below is a draft of a form that would be initialed or signed and then kept in the patient's medical record. Most people pay closer attention when required to write something that would be available for subsequent review in the event of a problem.
2. It would be a requirement that the surgeon have his/her patient's medical record in the OR. The surgeon would affirm (in writing) that the operative site marked earlier in the pre-op holding area agrees concerning site and side with (1) the surgeon's office record and (2) the patient's signed consent form.
3. I'd consider making the anesthetist a more involved party. The anesthetist would confirm (in writing) that the site and side affirmed by the surgeon agree with the information in the anesthetist's pre-op records.
New guidelines for managing this sort of problem might best come out of a committee comprised of representatives of key stakeholders in the process: surgeons, nurses, anesthetists, administrators, maybe a trustee, maybe a representative of the public. The committee's chair should be an experienced surgeon. A surgeon would be the person most familiar with how the diverse components of the problem interrelate. Also, the product of the committee's work would have more credibility in the minds of surgeons if they felt this were a surgeon-led effort.
Please forward this to Ken Sands and Paul Levy.
CONFIRMATION OF PRE-OPERATIVE "TIME OUT" CONFERENCE
SURGEON I affirm: a) the patient in this operating room is the patient identified by the label on this page; b) the procedure I will perform is: c) the SIDE for the procedure is (box) LEFT (box) RIGHT; d) the procedure and side noted in b) and c) above agree with (1) my pre-operative record and (2) the patient's operative consent form, copies of which are in this room. SITE and SIDE as noted in these records agree with my pre-operative marking on the patient's skin. Affirmed: (signature or initials, name printed)
a) the patient for whom I am administering anesthesia is the patient identified by the label on this page; b) the procedure to be performed as recorded on the CONSENT FOR ANESTHESIA is:
c) the SIDE for the procedure recorded on the CONSENT FOR ANESTHESIA is (box) LEFT (box) RIGHT.
Confirmed: (signature, name printed)
CIRCULATING NURSE I confirm: a) the patient in this operating room is the patient identified by the label on this page; b) the procedure to be performed is: c) the SIDE for the procedure is (box) LEFT (box) RIGHT. Confirmed: (Signature, name printed) Date: ________________ Time: ____________
OK, here are my comments. First, note the "bolt-on" nature of the solution, i.e., an add-on type of approach. Replacing single-point failure with dual-point failure might be an improvement, but in our recent event no one exercised their prerogative and obligation to ask about the timeout. We know from other settings that filling out a form does not ensure compliance with underlying safety requirements. Forms tend to get signed even when the action to have been taken was not. We need a solution that creates an expectation of compliance from everyone in the room, and freedom to point out a lack of compliance by any other member of the team.
How about this? "The committee's chair should be an experienced surgeon. A surgeon would be the person most familiar with how the diverse components of the problem interrelate." I think this could lead us awry. Every person in (and indeed outside of) the operating room has an important and unique view of how things interrelate. Instead of establishing a surgeon as chair of the committee, perhaps there should be a more neutral facilitator, part of whose job is to make sure that all those viewpoints are taken into account. Also, I wonder if a committee or task-force approach to this kind of issue is the way to go or whether a more broadly based community of people should be involved.
Your turn! Teach me and this surgeon what you have learned.