An article was published in the Boston Globe this week about a wrong site surgery that happened at the Beth Israel Deaconess Hospital (BIDMC) on Monday (see http://www.boston.com/news/health/blog/2008/07/surgeon_operate.html). Unfortunately, wrong site surgery continues in many hospitals in spite of all of the attention placed on prevention. Why does this continue? Here are two likely contributors.
1. Nobody is paying attentions to the broken care processes that support the high profile safety initiatives. Even though my blog post from last week did not depict BIDMC, the chaotic OR work environment that the nurse describes in her hospital has parallels in almost every US hospital. Nurses spend as much as 45% of their time looking for missing instruments and equipment every day – if everyone is hunting and gathering just to get a case going, is it any wonder that site verification and the safety pause gets overlooked? There’s another systems principle that states that an organization will only measure what it considers to be important – if it’s not measured, it’s not important. Reflect on the computer entries for OR efficiency in my preceding post and you will notice that the only thing that’s important is getting into the room on time; there’s no valuable measure of the underlying process for room preparation that would flag anything that the nurse describes. If it’s not measured, it’s not important.
2. We have misunderstood the use of inspection in a quality process. Here’s a fundamental rule on the use of inspectors: they are not to be used as part of the quality process; instead they are there to identify problems that have already occurred in the process so that they can be fixed! Further, the more inspectors you have the worse the quality oversight; nobody takes responsibility for overseeing the process. Think about how we do site verification. Every care provider involved is typically responsible to site verify before they do anything with the patient. Most of the time every care provider is already multi-tasking, hunting and gathering and doesn’t have the time to be thorough; “No problem,” they think, “somebody else will catch any issues I miss before we get to the OR.” The patient comes into the OR, and now we have the safety pause being performed by everyone who has already done their own verification process in preop: think they’re focused, especially now where they’re under pressure to get the case started? To them it’s a redundant formality and there are more important things to do.
Food for thought:
Care providers are set up for failure when they work within these care and quality processes. The 90/10 rule rears it's ugly head again to create catastrophic patient harm! Until we make these underlying care processes visible and fix them with frontline input, we don’t have a prayer in eliminating wrong site surgery. We also have to learn to use inspection (site verification and the safety pause) in a way that it can be effective – with undiluted accountability and to improve the care process.
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I will be on vacation next week, so no blog post until the week of 7/14/08.
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