The Problem of Wrong-Site Surgery - Research Paper Example

? Evaluating a guideline College This paper aims at evaluating a surgical guideline as recommended by the Universal Protocol created by the Joint Commission on Accreditation of Healthcare Organizations JCAHO. The universal protocol aims at preventing wrong site, wrong procedure, and wrong person surgery. To enable this, I am going to critically examine a number of published articles regarding the same. All the articles to be analyzed share the components of the universal protocol: teamwork, communication and the goal of the overall safety of the patient. This paper finds out that effective implementation of the Universal Protocol significantly reduces cases of wrong site, wrong procedure, and wrong person surgery. Keywords: wrong site surgery, universal protocol, time out. Evaluating a guideline: Universal Protocol (Timeout) The universal protocol for preventing wrong site, wrong procedure and wrong person surgery was approved by the Joint Commission Board of Commissioners in July 2003. However, it took one year before it was effective in July 1, 2004 for all accredited hospitals, ambulatory care and office-based surgery facilities. There was an increasing and continuing occurrence of wrong site, wrong procedure and wrong person surgery that prompted the creation of the universal protocol of the Joint Commission. The university protocol incorporated a series of requirements under the Joint Commission’s 2003 and 2004 National Patient Safety Goals. The universal protocol involves a number of steps, viz: 1.) A preoperative verification process which entails verifying a checklist to confirm that the relevant and appropriate documents (e.g., medical records, imaging studies) are available. Preferably, this process should take place when the patient is awake and aware. 2.) Marking the operative site which entails involving the patient in the marking process of the surgical site. In this process, make sure to use unambiguous marks. 3.) “Time-out” or “Surgical Pause” immediately before starting the procedure. This process helps the surgeons to correctly identify the correct patient, procedure and site (Joint Commission, 2003). In hospitals and surgical centers, it should always be ensured that the patient feels safe and confident. This can be possible through the use of the universal protocol. Nurses who are involved in this should help maintain patient safety by utilizing the universal protocol. Literature review In the search strategy, databases used were from Jacksonville University online resources. The databases included EBSCO and ScienceDirect. Both PubMed and CINAHL PLUS databases were systematically searched between 1990 and March 2007 to identify both theoretical and empirical data that discussed the implementation process for the universal protocol recommendations. Searches were also conducted from January 1, 1999- October 31, 2008. The search terms used were: wrong site surgery, universal protocol, time out, and universal protocol implementation. A review of literature shows that an effective implementation of the Universal Protocol will tremendously reduce cases of wrong patient, wrong site and wrong procedure. It will increase the safety of patients in hospitals and surgical centers. Rogers (1989) developed one of the most adopted theories of nursing, the concept of “Science of Unitary Human Beings and Principles of Homeodynamics.” In her theory, Martha Rogers postulates two major nursing ideas. These include: 1.) Nursing exists to serve people- it is a science and at the same time an art that is humane and humanistic. 2.) Nursing Science seeks to promote how persons co-exist with and interact with their environments. Rogers’ model of the Science of Unitary Human beings has some concepts that provide a framework for nursing practice. To start with, the Unitary Human being (person) is regarded as a unified whole which cannot be predicted from knowledge of the parts and having its own distinctive traits which cannot be perceived by looking at, describing, or summarizing the parts. Secondly, there is openness between people and the environment. This lack of barriers between the two allows them to constantly exchange energy back and forth. Thirdly, uni-directional or pan-dimensionality is a building block for this concept. It means that life process exists along an irreversible space time continuum. Fourth, patterns identify individuals and reflect their innovative wholeness. Lastly, individuals have diverse thoughts and sentience. They are capable of abstraction and imagery, language, and also emotion. Discussions Mulloy and Hughes (2008) wrote on a preventable medical error and a near miss that occur in surgery. This is the Wrong-site Surgery (WSS) which entails performing surgery on the wrong side or site of the body, wrong surgical procedure performed, and/or surgery performed on the wrong patient. In their research, they evaluated the effect of the implementation of the correct site surgical toolkit and if there was a change in the incidence of wrong site surgery. To accomplish this, they critically looked at the cause and consequences of wrong-site surgery, and made recommendations for prevention using the Universal Protocol. Generally, WSS occurs when a formal system to verify the site of the surgery leaks or there is a lack of a breakdown of the system that verifies the correct surgery site. Communication failure (70%), procedural non-compliance (64%) and leadership (46%) were found to be the root causes of WSS (Mulloy & Hughes, 2008). Wrong-site surgery has been found to have very severe effects or negative impacts both on the patient and the surgical teams. For instance, penalties are being imposed on surgeons for wrong-site surgery. Nonetheless, some medical insurers have gone ahead to decide that they neither pay providers for wrong-site surgery or surgery performed on the wrong person, nor for foreign objects left in the body of a patient after surgery. The incidence of wrong-site surgery that was reported to have increased in the past years e.g., in 1998 there were 15 cases compared to the 592 cases reported in June 30, 2007 in the United States. In its National Patient Safety Goals, the Joint Commission issued two goals to target wrong-site surgery. The first goal was to improve the accuracy of patient identification by using two patient identifiers and a “time out” or “surgical pause” procedure before insidious procedures. Secondly, the Joint Commission issued a goal to help in eliminating wrong-site surgery, surgery on the wrong person, and wrong procedure surgery using the pre-operative process to mark the site while involving the patient and verification process to confirm documents (Mulloy & Hughes, 2008). Realizing the importance of the universal protocol for WSS, the Association of preoperative Registered Nurses (AORN) in collaboration with the Joint Commission developed a “Correct Site Surgery Tool Kit” which was endorsed by: the American College of Surgeons, American Society of Anesthesiologists, and American Society for Healthcare Risk Management, American Hospital Association, and the American Association of Ambulatory Surgery Centers. This tool was designed to help in the implementation of the universal protocol for WSS. Most health care organizations have tried to effectively implement the correct site surgery tool kit. However, cases of WSS continue to be reported increasingly as health care facilities become more and more transparent to medical error. Teamwork and Communication in the Operation Room (OR): Makary, Sexton, Freischlag, Holzmueller, Millman, Rowen, and Pronovost (2006) did a study on “Operating Room teamwork among physicians and nurses.” The aim of their study was to measure teamwork in the OR setting. Breakdowns in communication, as recently identified by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), is the leading root cause of wrong-site operations, and other sentry events. For safe hospital systems and patient safety, hospitals are obligated to “promote effective team functioning” as concluded by the 1999 Institute of medicine report on medical error. Makary et al. (2006) found out that there existed substantial inconsistency in perceptions of teamwork in the OR. Physicians rated the teamwork of others as well, and on the other hand, the OR nurses did not reciprocate the high ratings given by physicians and perceived teamwork as poor. These discrepancies might be attributed to the differences in status, authority, gender, training, and patient-care responsibilities. On the same note, nurses often describe good teamwork as having their impact felt and respected, while for the physicians, good collaborations entails nurses who anticipate their needs and follow their instructions. Nevertheless, nurses might be hesitant to approach the surgeon for a number of reasons. For instance, nurses may perceive the surgeon as unapproachable or nurses may feel that they are inferior to and have lesser training and experience in dealing with the patient’s medical condition. Such issues will not only compromise the patient’s safety but also bring about nurses’ job dissatisfaction (Makary et al., 2006). Makary et al. (2006) postulates that in order to improve teamwork and communication in the OR, briefings and debriefings should be carried out. This will help the team members to know each other, the operative plan, and the potential issues in the case. A debriefing will help the team to learn lessons from the case for future reference. This has shown positive results as used at the Johns Hopkins Hospital. To study the implications of teamwork and communication in surgical teams for patient safety, Mills, Neily and Dunn (2008) also did a study to help improve communication within the healthcare community. The results of this study were consistent with those of Makary et al. (2006). The results indicate that substantial discrepancies among nurses and physicians in the physicians/surgeons perceive a high rating of organizational culture of safety, better teamwork and communication than their counterparts either nurses or anesthesiologists do. Communication failures in the OR are not rare and can put patient’s safety at risk (Lingard et al., 2004). The results revealed by Mills et al. (2008) indicated the usefulness of the Medical Team Training (MTT) questionnaire in identifying the discrepancies in the perception of teamwork and communication effectiveness between physicians and nurses in the surgical environment. Altpeter, Luckhardt, Lewis, Harken and Polk (2007) described the experience of one health care institution with the Surgical Time Out (STO) technique and tried to validate its potential use by others. This technique entails taking some pause before the invasive operation procedure to verify the patient’s identity and the correct site operations. Although the method of surgical time out constitutes two core components- identification of the patient and verification of the correct site- there are five other components of equal importance (Altpeter et al., 2007). These include: prophylactic antibiotics, normothermia, venous thromboembolism, euglycemia, and finally ?-adrenergic blockade. The study found out that the use of surgical time out was very effective in increasing patient safety, and reduction of errors. Following these findings, other hospitals, surgery centers, physicians and OR nurses are largely encouraged to use surgical time out for briefings and debriefings before any invasive operation procedures. This will definitely enhance the contemporary surgical quality improvement (Altpeter et al., 2007). Conrardy, Benek & Myers (2010) study was to determine the state of knowledge for implementing the universal protocol recommendations. Significant trends, gaps, and areas of concern in the implementation process were noted in various facilities where the current state of knowledge vary from one facility to another. When the universal protocol is successfully implemented, there will be; increased teamwork and communication, active staff/patient participation, and finally supportive hospital leadership/administration that promotes a healthy work environment (Conrardy et al., 2010). From the review of literature and data analysis, Conrardy et al. (2010) grouped significant trends into six major focus areas. These include: 1.) Universal protocol elements- patient identification, verification of the correct site surgery and time out or surgical pause. 2.) Communication between surgical team members- both positive and negative aspects. 3.) System process- patient safety, procedural compliance, equipment setup, checklists, monitoring systems, redundant verification, new technology, and simplification/standardization of process. 4.) Team performance- staffing, multiple surgeons, scheduling etc.. 5.) Patient assessment- multiple procedures, and emergencies. 6.) Organizational/cultural behavior- participation of the leadership/administration and root cause analysis. Gaps were also identified as missing or confusing elements of the universal protocol recommendations, such as patient identification, site marking and verification, or the surgical time out. The identified gaps were classified into three major sets: universal protocol elements, measurement tools, and data on the efficacy of the universal protocol. Nonetheless, areas of concern were also identified as alarming issues regarding the implementation process of the universal protocol. These areas of concern were grouped into: surgical team members’ behavior, data clarification, universal protocol process variations, and efficacy of the universal protocol. From there integrative review of literature, Conrardy et al. (2010) found out that the current state of knowledge on the implementation of the universal protocol varies from facility to facility. The differences in adaptations of the universal protocol elements and the inconsistent compliance of the universal protocol process are the reasons behind these adaptations. Biehn (2008) did a descriptive study that focused on the attitudes, beliefs, and perceptions of operating room personnel. The study was conducted by the use of a questionnaire that sort the response of 109 operating room personnel. The findings of the study were reported as percentages and frequencies. All the participants in the study affirmed that policies and procedures to prevent wrong-site surgery were instituted where they worked. The participants perceived that procedures such as marking the surgery site on the patient’s skin and having a surgical pause or time out could prevent wrong-site surgery. One of the perceived biggest factors contributing to wrong-site surgery was pressure to speed up the case. Despite the mandated efforts to prevent the occurrence of wrong-site surgery, it continues to occur although not common. The results showed that nurses’ beliefs, perceptions and attitudes are necessary to continue to prevent wrong-site surgery. This implies that, nurses play an important role in the safety of patients while undergoing surgical procedures. Recommendations All the articles examined share the elements of the universal protocol: teamwork and communication and the overall goal of patient safety. They are all in support of the guidelines of the universal protocol. They show that correct implementation and use of the universal protocol can tremendously reduce the amount of wrong site, wrong patient procedures. I therefore suppose that no changes should be made in the guideline. However, since the adaptations vary from one facility to another, each facility should customize the process to fit their way. Conclusions and future research To prevent future increases in the incidence of wrong-site surgery, training, collaboration and education of the OR nurses is necessary. Most researchers have affirmed the necessity for further research to reduce the occurrence of and prevent wrong-site surgery (Biehn, 2008). Future research also calls for the evaluation of whether the increase in clarity and specificity of the universal protocol implementation will enhance its effectiveness (Mulloy & Hughes, 2008). Studies in the nursing industry can also be carried to identify strategies to enhance the use of the universal protocol (Conrardy et al. 2010). Future research could also concentrate on identifying successful strategies, and best practices for the implementation of the universal protocol. References Altpeter T, Luckhardt K, Lewis JN, Harken AH, Polk HC., Jr. (2007).  Expanded surgical time out: a key to real-time data collection and quality improvement.  Journal of the American College of Surgeons, 204 (4): 527-532 Biehn, M. A. (2008). Wrong-site Surgery: Attitudes, beliefs and perceptions of operating room personnel. Northern Kentucky University. Dissertations and Theses. Conrardy, J.A., Brenek, B., Myers, S. (2010). Determining the state of knowledge for implementing the universal protocol recommendations: an integrative review of the literature. Published by Elsevier Inc. All rights reserved. Joint Commission (2003). A universal protocol for preventing wrong site, wrong procedure, wrong person surgery. [Accessed April 19, 2013]. Available at http://www?.Joint commission?.org/NR/rdonlyres?/E3C600EB-043B-4E86-B04E-CA4A89AD5433?/0/universal_protocol.pdf. Lingard L, Espin S, Whyte S, et al. (2004). Communication failures in the operating room: an observational classification of recurrent types and effects. Quality Safety Health Care, 13:330–334. Makary MA, Sexton JB, Freischlag JA, et al. (2006). Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. J Am Coll Surg; 202:746–752. Mulloy, D.F. And Hughes R.G. (2008). Wrong-site surgery: a preventable medical error. J Bone Joint Surg. 85A:1849. [PubMed: 12954854] 24. Rogers, M. E. (1989). An Introduction to the Theoretical Basis of Nursing. Philadelphia: F. A. Davis Read More