Wrong-Site Surgery Occurs 40 Times a Week

From Medscape Medical News
Wrong-Site Surgery Occurs 40 Times a Week
Joint Commission Announces Preliminary Results of Project to Prevent "Never Happen" Events
Mark Crane


June 29, 2011 — Despite intense efforts to prevent wrong-site surgery in recent years, the adverse event "that should never happen" occurs about 40 times a week nationwide, the Joint Commission Center for Transforming Healthcare said today.

The center announced the preliminary results of a project with 8 hospitals and ambulatory surgery centers. The facilities found that problems with scheduling and preoperative/holding processes, as well as ineffective communication and distractions in the operating room, contributed to increasing the risk for wrong-site surgery. A "time out" without full participation by all key people in the operating room was identified as another contributing factor that increased risk.

"The 8 hospitals and [ambulatory surgery centers] identified where errors can creep into the process and took steps to correct them," Mark R. Chassin, MD, FACP, MPP, MPH, president of the commission, said during a news conference today. "We hope to use their experience as a roadmap to measure risks.

"All facilities and physicians who perform invasive procedures are at some degree of risk," he said. "The magnitude of this risk is often unknown or undefined. Providers who ignore this fact, or rely on the absence of such events in the past as a guarantee of future safety, do so at their peril. Unless an organization has taken a systematic approach to studying its own processes, it is flying blind."

Because wrong-site surgeries are relatively rare events, they are difficult to study. Research has shown that there is usually no single root cause of failure. Instead, such events are frequently the result of a cascade of small errors. "There's no silver bullet or easy answer," Dr. Chassin said.

Wrong-site surgery includes invasive procedures on the wrong patient in addition to wrong-procedure, wrong-site, and wrong-side surgeries. In 2010, it was the third most common sentinel event reported, Dr. Chassin added.

The 8 facilities found that addressing documentation and verification issues in the preoperative/holding areas decreased defective cases that increase the risk for wrong-site surgery from a baseline of 52% to 19%. In turn, the incidence of cases containing more than 1 defect decreased 72%.

"We found that in 39% of cases, errors were introduced that increased risk," he said. "The biggest was inadequate information about the patient. Often, the information is taken by a staffer in the surgeon's office, who may have to deal with several hospitals and different protocols. Confusion can result. The solution is a carefully standardized way of collecting information."

Marking the incision site varies greatly within facilities, increasing the risk for a preventable error. "In the past, the mark was made in the holding area," said Mary Reich Cooper, MD, JD, senior vice president and chief quality officer of Lifespan Corporation, which has 4 hospitals in Providence, Rhode Island.

"We found discrepancies between what was seen there before the surgeon arrived and what he thought he was doing in the operating room," Dr. Cooper said. "So now we have surgeons go out to the holding area to make the initial mark. Then in the [operating room,] before the procedure starts, we affirm that mark, asking if everyone sees the mark. We shut down our [operating room] for a day and put everyone through training. Every new staffer gets the same training."

Dr. Chassin noted that unapproved pens had been used to do the marking. "Sometimes, the mark was washed away during the prep," he said. "So make certain that only approved indelible pens are used. This was a simple but important intervention."

Time-outs were handled inconsistently in several locations. "Was the time-out occurring before prep and drape, or after? Who leads the time out? The circulating nurse or the attending surgeon?" said Tom Feldman, chief executive officer, Center for Health Ambulatory Surgery Center in Peoria, Illinois. "We closed some gaps and decreased variation. That helps everyone in awareness."

"At the time-out, we stop all activities so we can all focus on this last opportunity to correct a mistake," said Dr. Cooper. "Everyone needs to stop what they're doing. We script the staff to ask if everyone can see the mark. Everyone must respond before the operation proceeds."

Dr. Chassin urged physicians and hospitals to view the joint commission's Targeted Solutions Tool, which provides a step-by-step process to measure performance. The first set of solutions focuses on improving hand hygiene. Additional solutions for wrong-site surgery will be added in the fall. Solutions for problems with hand-off communication will be added later in the year.

The 8 facilities that volunteered for the project are AnMed Health, Anderson, South Carolina; Center for Health Ambulatory Surgery Center, Peoria; Holy Spirit Hospital, Camp Hill, Pennsylvania; La Veta Surgical Center, Orange, California; Lifespan-Rhode Island Hospital, Providence; Mount Sinai Medical Center, New York City; Seven Hills Surgery Center, Henderson, Nevada; and Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Medscape Medical News © 2011 WebMD, LLC
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Hypnosis Has Benefits in Breast and Thyroid Surgery

Something Interesting I thought I'd post on our blog!

From Medscape Medical News
Hypnosis Has Benefits in Breast and Thyroid Surgery
Megan Brooks
June 14, 2011 — For certain types of breast and thyroid surgery, a combination of hypnosis and local anesthesia is feasible, can aid in the healing process, and can reduce drug use and time spent in the hospital, according to 2 studies reported at Euroanaesthesia 2011: the European Anaesthesiology Congress in Amsterdam, the Netherlands.
Fabienne Roelants, MD, and Christine Watremez, MD, from the Department of Anesthesiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain in Brussels, Belgium, reported their group's experience with hypnosis and local anesthesia in certain breast surgeries and video-assisted thyroidectomy.

In the breast surgery study, the clinicians took a look back at 78 women who underwent quadrantectomy and sentinel node biopsy or axillary dissection under hypnosis and local anesthesia (n = 18) or under general anesthesia (n = 60) between January and October 2010.
Hypnosis was induced using standard progressive muscle relaxation hypnotic techniques, described by Milton H. Erickson, MD, the American psychiatrist who pioneered medical hypnosis. Hypnosis was initiated in the operating room at the time of local anesthesia and continued throughout the surgery.
Local anesthesia was performed by the surgeon (lidocaine 0.5% plus levobupivacaine 0.25%). A continuous infusion of remifentanil (0.05 μg/kg per min) was increased as needed. In the general anesthesia group, anesthesia was induced with propofol, ketamine, clonidine, lidocaine, and sufentanil.
According to the researchers, there was no difference in length of surgery in the 2 groups. Although women who were hypnotized spent a few minutes more in the operating room (122 vs 116 min), perioperative drug use was reduced, as was time in the recovery room and in the hospital. No patient in the hypnosis group converted to general anesthesia during surgery.

There was also less fluid drainage in the hypnosis group (24.7 vs 61.4 mL; P = .02), which the researchers say "may be the result of posthypnotic suggestion."
"Being able to avoid general anesthesia in breast cancer surgery is important," Dr. Roelants said, "because we know that local anesthesia can block the body's stress response to surgery and could, therefore, reduce the possible spread of metastases."

Hypnosis for Video-Assisted Thyroidectomy
Dr. Roelants and Dr. Watremez have had similar success using hypnosis and local anesthesia in patients undergoing video-assisted thyroidectomy. In their second study presented at the meeting, hypnosis was induced with a combination of standard eye fixation and progressive muscle relaxation hypnotic techniques, also using the Erickson approach. The use of local and general anesthesia in this study mirrored that in the breast surgery study.

The clinicians report that drug use and length of stay in the recovery room and hospital were lower in the 18 patients who underwent the surgery after hypnosis and local anesthesia than in the 36 patients who received general anesthesia.

There was less nausea with hypnosis, the researchers say, and no difference in pain scores in the recovery room. Patient satisfaction scores were higher in the hypnosis group, and no one in the hypnosis group converted to general anesthesia during surgery.

Hypnosis "Flat Out Works"
In all the surgeries studied, "local anesthesia is feasible but not, on its own, sufficient to ensure patient comfort," Dr. Roelants noted in a statement from the meeting.
"This is not the first study using hypnosis in thyroidectomy patients, but it is the first study using hypnosis for video-assisted thyroidectomy," Dr. Roelants and Dr. Watremez noted in an interview to Medscape Medical News.
"It takes special training in hypnotic techniques, especially the techniques that reduce anxiety and pain. In our hospital, almost half of our staff will be trained in hypnosis at the end of this year," they said.
Reached by telephone for comment, Guy H. Montgomery, MD, from Mount Sinai School of Medicine in New York City, said that these 2 studies appear to be "strong" and provide more data that hypnosis can be effective in surgery.
"Hypnosis for surgery has been around since before ether. There are meta-analyses on the use of hypnosis in surgical patients, and the effect sizes are typically large. It's one of the areas where it just flat out works," he said.

Dr. Montgomery was not involved in the 2 studies, but has conducted research on hypnosis. A study of his published last year looked at the underlying mechanisms responsible for hypnotic effects in breast surgery patients (J Consult Clin Psychol. 2010;78:80-88).

"We found that for pain reduction, things like changing your expectation and reducing stress are huge in terms of accounting for how hypnosis works," he said.
The study investigators and Dr. Montgomery have disclosed no relevant financial relationships.
Euroanaesthesia 2011: the European Anaesthesiology Congress. Abstracts 8AP5-4 and 8AP5-8. Presented June 12, 2011.