Creating a Culture of Safety:Challenges in Ophthalmology

James P. Bagian, MD, PEDirector, Center for Health Engineering

University of MichiganFounding Director, VA National Center for Patient

Safetyjbagian@umich.edu

Ensuring Correct Surgical Care

• What was the objective?

• What have we done?

• How have we done?

• What have we learned?

• What remains to be done?

What Was The Objective?

• Patient gets the best care possible• Diagnose and treat as intended

• No inadvertent harm• Incorrect surgery (aka Wrong-sided surgery)• SSI/HAI/DVT

What Have We Done?

• Public & Professional Recognition of Problem• NQF, Joint Commission, AAOS, AAO, etc.

• Guidelines, Regulations, etc.• NQF Serious Reportable Events• Joint Commission National Patient Safety

Goals• State, local, and organizational actions

NQF Serious Reportable Events

Joint Commission

Joint Commission

American Academy of Ophthalmology

• Steps Prior to Day of Surgery• “clinic and surgery areas…specific data be

passed between sites via written documentation rather than verbal”

• Steps On the Day of Surgery• “…proper eye should clearly be notated on

the consent form. “• “person who marks the eye should use written

documentation with verbal verification” • Timeout – All team members, patient, side,

implant, etc. Use “Hard Stop” if required

American Academy of Ophthalmology

• Checklist for the Surgery Chart • Pre-Op Area

• Patient ID, Procedure, Side• Eye marked

• Operating Room• Patient ID – name and birth date• Procedure & Side• Proper Implant – Style and Power• “Prior to draping, circulating nurse ensures that

operative plan is visible (post drape) so that the surgeon can read it while gowned and gloved. “

• “The circulating nurse writes the patient's name, operative eye, IOL style, and IOL power on the white board. “

How Have We Done?

• Problems still exist

How Have We Done? - VA

• 2001-2006 Experience (All Specialties)• 108 OR adverse events reported• Ophthalmology and Orthopedics the highest

reports although not most common procedures

• Communication (inadequate timeout) and Patient Mis-Identification played major role

• Wrong side >40%• Wrong Implant >30%• Wrong Site/Patient/Procedure each approx.

10%Neily et al. Incorrect Surgical Procedures …Arch Surg 2009 Nov;144(11):1028-34

What Have We Learned? - VA

• Actions needed well before entering the OR• Timeout period is too late in many cases• Systems-based approaches beyond individual

• Involvement of all disciplines

• Structured communication that drives discussion• Briefings & debriefings, Medical Team

Training essential

Supporting Long Term Memory

• Checklists• Put knowledge in the world vs. in the head • Recognition is better than recall

• Checklist Philosophy• “Read and Verify” checklists• “Read and Do” checklists

Checklist-Driven Preoperative Briefing

Antibiotic Prophylaxis

DVT Prophylaxis

Vertical Hierarchy

• “Silence Kills”. Team members uncomfortable “speaking up” when something does not seem right in a patient’s care, leading to patient harm.

• Poor communication between team members leading to a lack of situational awareness and a poor clinical decision resulting in patient harm.

• Did Medical Team Training (MTT) improve either of these baseline healthcare problems in our Organization?

Has MTT improved the Care of the Veteran?

• “Catches” in the Operating Room.

• Surgical morbidity and mortality.

Preventing Harm

June 1, 2009 MTT Update: 110 facilities

144 Undesirable Events Prevented

Improved OR Efficiency Following MTT

Following MTT . . .

MTT Status Update June 1, 2009, 110 Facilities.

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10%

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Pre Post

Operating Room

Nursing Turnover

P = 0.02

45 Operating Rooms and 35 Intensive Care Units

Pre = 12 Months Prior to Learning Session

Post = 12 Months Following Learning Session

2525

Outcomes – Morbidity / MortalityObserved / Expected Mortality Ratios

Quarters of MTT

August 19, 2009 MTT Preliminary Report : N = 99 facilities.

P = 0.03

Summary - Gaps• Systems Approach – Surgical issues must be

dealt with in the extended peri-operative period, not solely in the OR • Entire system of care must be examined and engineered

with desired results in mind – avoid unintended consequences

• Patient Identification• Antibiotic Prophylaxis• DVT Prophylaxis

• Implant Use

• Checklist-guided briefings and debriefings• Can’t rely on individuals being careful (vigilant)

• Team Training – start in initial training & sustain• More than SBAR – Leadership Must Be Involved