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November / December 2005
One Couple:
Same Name, Same Date, Same Surgery
By Kristina A. Krail, RN
After concluding a phone conversation with a popular orthopedic surgeon, I hung up the receiver, slowly and silently shaking my head to myself. As chief nursing officer, I was happy that the medical staff felt comfortable enough to talk to me directly about their complaints, requests, and commentary. However, I was also frequently surprised as to the subject matter they felt was worthy of a telephone call. It was late in the day and there was no one around to validate my gut feelings, which were so contrary to the position of the physician with whom I had just finished speaking.
He wanted to give me a "heads-up." He had a joint replacement scheduled for the following week...two in fact. It was nothing unusual or unmanageable until he shared the detail that it was a husband and wife. The surgeon was pleased with himself that he was simultaneously treating the pair pre-operatively in his office and that he had arranged for their surgery and hospitalization to coincide as well. He said the media had even been following the couple the local newspaper felt it might turn into a nice human-interest story. I did not share his enthusiasm. And, although I could imagine the eagerness of some reporter writing a heartwarming story about how a local senior couple struggled with the challenges of degenerative joint disease to brave surgery together so that they may walk off into the sunset with replaced and functioning knees, I knew the potential dark side of such a story. These two patients same name, same procedure, same doctor, and same surgery date could be direct witnesses, along with their reporter, to the numerous life-threatening mistakes, errors, and mix-ups for which we were potentially setting them up.
It was the landmark report in 2000 from the IOM Committee on Quality of Health Care in America, To Err Is Human: Building a Safer Health System, that spotlighted to society (and the healthcare industry) serious breaches in patient safety. The now-famous statistic that as many as 98,000 hospitalized patients die each year not due to illness, but due to errors, shocked everyone. The comprehensive tome encapsulated the vast issue of "patient errors" along with its human and economic toll. In the IOM's study of adverse events, a line list of safety problems included, among other things, mistaken identity and wrong-site surgery. Their review concluded that more than two thirds of the adverse events were thought to be preventable and that the healthcare industry would be irresponsible if it did not respond to the challenge to improve (IOM, 2000).
Several days later I discussed the "husband and wife" surgical case with our nursing quality improvement coordinator. My initial emotion of concern about the hospital's ability to safely care for these patients had gradually morphed into feelings of optimism. I believed if we could concurrently track their hospital experience, we could protect them from harm at the same time. My inspiration was not that far-fetched. The concept was right in line with the new JCAHO tracer methodology, which is an important component of the Shared Visions-New Pathways accreditation process.
Hospitals are now required to complete a pre-survey periodic performance review or PPR. This assists JCAHO surveyors in identifying those areas where patient safety and quality of care are most important, as well as areas of deficiency that need further evaluation. Armed with these priorities, the surveyors then assess for standards compliance by using the tracer method. Surveyors select particular patients to assess the system in question, while utilizing the medical record as a roadmap. The process can validate the coordination and consistency between departments and care providers while proving compliance with the standards. Or, it can bring to light potential vulnerabilities and gaps in the care process (DeLorenzo, 2005). Indeed, quality improvement experts recommend using the tracer methodology as a tool for change that can be leveraged for its utility beyond survey preparation purposes. It is an excellent way to zoom in on "risk points," question staff, collect data, verify policy and procedure compliance, and engage patients (DoBias, 2005).
The nursing QI coordinator signed-on to concurrently trace our "surgical couple" as a performance improvement exercise to measure our compliance with two important patient safety standards. The hospital had recently implemented several policies and practices in response to the issuance of National Patient Safety Goal #1: to improve the accuracy of patient identification. This would give the nursing department a chance to measure our compliance first hand and in real time. Secondly, the operating room had just concluded fully embracing the Universal Protocol as a mandated safeguard against wrong-site surgery. What better way to stand witness to its implementation than to see it in action on two patients with the same name, having the same site specific procedure, back to back, on the same day.
"Let's start right now," the QI coordinator stated.
And, although the hour was late, she dragged me upstairs to the pre-surgical testing (PST) unit. The procedures were scheduled to take place in less than a week, so she knew that we had already commenced caring for these patients. The PST nurse retrieved the patients' records, and she was surprised to learn we were investigating because they were married and having the same procedure on the same day. She didn't realize it, and the charts certainly did not indicate any potential problem. We quoted the new policy and procedure for patient identification, but it seemed that the outpatient PST department didn't know how it applied to their area. So before the patients were even admitted, we came to the harsh realization that we could have failed them.
Lesson 1:
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