New Patient-Safety Goals Address Medical Errors, Wrong-Site Surgeries

New Patient-Safety Goals Address Medical Errors, Wrong-Site Surgeries

By Kelly M. Pyrek

Confusion in identifying patients, miscommunication among caregivers, wrong-site surgery and medication mix-ups are among the issues addressed by the national patient-safety goals for 2003 set by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

For each of the goals, there are evidence-based recommendations to help healthcare organizations reduce specific types of healthcare errors. On Jan. 1, 2003, the JCAHO-accredited healthcare organizations that provide care relevant to these patient-safety goals will start being evaluated for compliance.

"The know-how to prevent these errors exists," says Dennis S. O'Leary, MD, JCAHO president. "We now need to focus on making sure healthcare organizations are actually taking these preventive steps."

The 2003 National Patient Safety Goals and recommendations include:

• Improve the accuracy of patient identification. Use at least two methods of patient identifiers (neither are to be the patient's room number) whenever taking blood samples or administering medications or blood products. Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a "time out," to confirm the correct patient, procedure and site, using active, not passive, communication techniques.
• Improve the effectiveness of communication among caregivers. Implement a process for taking verbal or telephone orders that requires a verification "read-back" of the complete order by the person receiving the order. Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to use.
• Improve the safety of using high-alert medications. Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride greater than 0.9 percent) from patient-care units. Standardize and limit the number of drug concentrations available.
• Eliminate wrong-site, wrong-patient and wrong-procedure surgery. Recommendations: Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents are available. Implement a process to mark the surgical site and involve the patient in the marking process.

The 2003 patient-safety goals were developed by an expert advisory group comprised of physicians, nurses, risk managers and other professionals.

In May 2002 the National Patient Safety Foundation (NPSF) launched a consensus initiative focused on improving patient safety in ambulatory surgery settings. This endeavor, "Ambulatory Surgery in the Office Setting," is in response to increasing concern among members of the medical community about how to ensure patient safety when surgery is performed in a doctor's office environment.

"Convening diverse stakeholders is an effective way of developing and implementing action for patient safety in ambulatory surgery," said Louis Diamond, MB, ChB, NPSF's director of programs. "We are pleased to join with such reputable and experienced organizations to work together to achieve a safer environment for the patient. It comes down to communicating, exchanging information and putting ideas into action.

"Ambulatory Surgery in the Office Setting" will provide a framework for action plans and ultimately an outline of applicable patient safety improvement solutions. The initiative includes developing a national agenda with prioritized action items for improved patient safety in ambulatory surgery; producing a report outlining the current landscape of patient safety in ambulatory surgery and developing partnerships and work teams to pursue planning and implementation of action

Medical errors were brought to the forefront with the publishing of the 1999 Institute of Medicine (IOM) report, "To Err Is Human: Building A Safer Health System." The report indicated that as many as 44,000 to 98,000 people die in hospitals each year as the result of medical errors.

The IOM report discovered medical errors occur in hospitals as well as physicians' offices, ambulatory surgery centers and urgent care centers. The IOM report estimates that medical errors cost approximately $37.6 billion each year, with about $17 billion of those costs associated with preventable errors.

Americans' awareness of medical errors is growing. According to a survey by the Kaiser Family Foundation, 51 percent of Americans followed closely the release of the IOM report on medical errors. A national poll conducted by the National Patient Safety Foundation found 42 percent of respondents had been affected by a medical error, either personally or through a friend or relative and 32 percent of the respondents indicated the error had a permanent, negative effect on the patient's health. Overall, survey respondents thought the U.S. healthcare system was "moderately safe."

Most people believe medical errors are the result of the failures of individual healthcare providers. When asked in a survey about possible solutions to medical errors, 75 percent of respondents thought it would be most effective to "keep health professionals with bad track records from providing care." Sixty-nine percent thought the problem could be solved through "better training of health professionals."

Examples of medical errors ripped from the headlines include:

• A Florida woman reportedly lapsed into a coma after undergoing a routine face lift and eye job.
• Two women reportedly developed kidney and intestine failure, blood poisoning and flesh-eating bacteria following liposuction. Both were near death before being admitted to a hospital. They are now permanently disfigured.
• A surgeon reportedly operated on the wrong side of a man's head after personnel at a Rhode Island hospital failed to follow procedures for preventing such errors. Staff placed the patient's computed axial tomography scan backward on the x-ray viewing box, so that it appeared that the patient's problem, bleeding on the brain, was on the left instead of the right. Staff failed to follow hospital policy requiring a final check to verify the patient's identity and the surgical site. Also, staff did not mark the surgical site with a pen, which error prevention experts strongly recommend.

The IOM defines medical error as "the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim." An adverse event is defined as "an injury caused by medical management rather than by the underlying disease or condition of the patient." Some adverse events are not preventable and they reflect the risk associated with treatment, such as a life-threatening allergic reaction to a drug when the patient had no known allergies to it. However, the patient who receives an antibiotic to which he or she is known to be allergic, goes into anaphylactic shock, and dies, represents a preventable adverse event.

Most people believe that medical errors usually involve drugs, such as a patient getting the wrong prescription or dosage, or mishandled surgeries, such as amputation of the wrong limb. However, there are many other types of medical errors, including diagnostic errors, equipment failures, nosocomial infections and misinterpretation of other medical orders.

Research shows that the majority of medical errors can be prevented. A landmark study on medical errors indicated 70 percent of adverse events found in a review of 1,133 medical records were preventable; 6 percent were potentially preventable; and 24 percent were not preventable. A study released last year, based on a chart review of 15,000 medical records in Colorado and Utah, found that 54 percent of surgical errors were preventable.

Other potential system improvements include use of information technology such as hand-held bedside computers to eliminate reliance on handwriting for ordering medications and other treatment needs; avoidance of similar-sounding and look-alike names and packages of medication; and standardization of treatment policies and protocols to avoid confusion and reliance on memory, which is known to be fallible and responsible for many errors.

Adverse events in surgery are the most frequent and costly type of medical error occurring in hospitals, according to statistics from the National Patient Safety Benchmarking Center, a repository of data on adverse events collected and analyzed by Safety-Centered Solutions, Inc. (SCS). Measurements show the top five most frequent adverse events -- surgery, medication errors, medical (nonsurgical treatment), patient falls, and nosocomial (hospital-acquired) infections -- account for 67 percent of the total events. The top five most costly adverse events -- surgery, medical (nonsurgical treatment), nosocomial infections, medication errors, and pressure ulcers -- make up 81.5 percent of the total costs in the database.

Adverse events in surgery account for nearly 20 percent of events in the national database; medication errors make up 16 percent; medical (nonsurgical) treatment, 14.8 percent; patient falls, 8.8 percent; and, rounding out the top five most frequent adverse events, nosocomial infections with 7.5 percent.

JCAHO cites the following statistics on the 126 wrong-site surgery cases in 2001: 41 percent relate to orthopedic/podiatric surgery; 20 percent to general surgery; 4 percent to neurosurgery; 11 percent to urologic surgery; 29 percent of incidents occurred in the inpatient operating room; 13 percent occurred at other inpatient sites, such as the emergency department or intensive care unit; 76 percent of cases involved surgery on the wrong body part or site; 13 percent involved surgery on the wrong patient and

11 percent involved the wrong surgical procedure. According to the Physician Insurers Association of America, there were 213 paid claims for wrong-site surgery claims between 1985 and 1997. The average indemnity payment was $54,800.

In the December 2001 issue of its Sentinel Event Alert, JCAHO reported that the number of wrong-site, wrong-person or wrong-procedure surgeries have grown tenfold since 1998. Taking issue with JCAHO's issuance of a Sentinel Event Alert on wrong-site surgery last winter was the Federated Ambulatory Surgery Association (FASA). The organization says JCAHO does not separate data for ambulatory surgery centers (ASCs) from data for hospital outpatient surgery departments so the data is not available on the exact extent of the wrong-site surgery problem. FASA questions whether there actually was an increase in incidences or whether the increase was the result of improved reporting.

"Even though a very small proportion of ASCs are accredited through JCAHO, every ASC should evaluate its processes to assure they are adequate to protect against such events," says Kathy Bryant, FASA executive director. FASA believes it is unlikely that wrong-site surgery is occurring disproportionately in ASCs.

For the second quarter of 2001, 68.2 percent of ASCs report a complication rate of less than three per 1,000 patient encounters, with 36.4 percent of ASCs reporting a complication rate of zero per 1,000. Almost 59 percent of ASCs did not report a single patient complaint of a substantive nature during that quarter.

The Association of periOperative Registered Nurses (AORN) statement on wrong-site surgery defines it as "a broad term that encompasses all surgical procedures performed on the wrong patients, wrong body part, wrong side of the body or at the wrong level of the correctly identified anatomic site." The responsibility for preventing wrong-site surgeries, AORN says, rests on the shoulders of the entire surgical team. According to AORN, "As patient advocates, perioperative RNs should communicate with all members of the surgical team to verify the correct surgical site."

Wrong-site surgery is a devastating problem that affects all surgical specialties and can stem from poor preoperative planning, a lack of institutional controls, failure of a surgeon to exercise due care or a simple mistake in communication between patient and surgeon. One method being used to eliminate wrong-site surgeries calls for the patient to watch and confirm as the operating surgeon's initials are signed with a permanent marking pen on the site requiring surgery. The surgeon then operates through or adjacent to these initials. The American Academy of Orthopedic Surgeons (AAOS) has developed this "sign your site" initiative to help combat wrong-site surgeries and is encouraging partnerships between the federal government, hospitals, physicians and other medical providers to initiate policies that will decrease medical errors.