One Couple: Same Name, Same Date, Same Surgery
November / December 2005
One Couple: Same Name, Same Date, Same Surgery
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:
Patient identification policies and practices need to include guidance for outpatient settings as well as inpatient settings.
We thumbed through the sheaves of paper that comprised the beginnings of their respective charts. “Aren’t you concerned that you could mix up these documents; both these patients have the same name?” I asked the staff. “Where are the ‘Same Name’ caution stickers?” the QI coordinator asked more urgently.
It was common practice, although not policy, to utilize pre-printed red labels that state, “CAUTION TWO PATIENTS WITH SAME NAME” when indeed there were two patients with the same name. Attentive staff would affix these labels to the chart, wristbands, room doors, menus, medication administration records, and just about anything else that was patient specific. And yet there were other hospital employees who were unaware that such a tool was at their disposal. We stirred around the unit station desk drawer and sure enough there was a roll of caution stickers. Together we labeled the charts.
Lesson 2:
Safety procedures, no matter how simple or commonplace, should be included in policy so that they can be referenced, perpetuated, and maintained.
A week later, sitting in the operating room station, I informed the staff of the husband-wife case study. I was beginning to feel assured that we had enough awareness and safeguards in place that we would not confuse Mr. “Knee Replacement” with Mrs. “Knee Replacement.” Now our focus switched to worrying about whether their first names were “Right” or “Left.” I glanced up at the posted OR schedule and noticed for the first time that the wife was having her right knee replaced and the husband was having his left knee done. What luck… another opportunity for serious failure.
It was 1996 when the JCAHO implemented its sentinel event policy. The program called for healthcare organizations to identify sentinel events (an unexpected death or serious injury), conduct a root cause analysis, and implement corrective action. This reporting to the JCAHO allowed them to collect and disseminate valuable information to all hospitals through the Sentinel Event Alertnewsletter. The newsletters included the underlying causes of the sentinel events, lessons learned, and ways to reduce the risks of future occurrences. Eventually, a Sentinel Event Advisory Group was formed and charged to develop the first set of National Patient Safety Goals based on a review of all Sentinel Event Alert evidence-based recommendations. The first set of goals included among other things “eliminate wrong-site, wrong-patient, and wrong procedure surgery” (JCAHO, 2005).
One hundred and fifty wrong-sited surgical sentinel events nationwide provided enough information to propose strategies that could permanently eliminate the problem. Specific recommendations included marking the site, involving the patient, creating a verification checklist, and obtaining an oral verification from all during a final “time-out” (JCAHO, 2001). In the end, a consensus document endorsed by more than 40 professional medical associations and organizations was issued as the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery (JCAHO, 2004).
Although our hospital practiced the Universal Protocol, I was still concerned we could make a grave error. How could all of us remember that the wife was right and the husband left? Even my casual mentioning to the OR staff present of “who was having what done” generated varying responses. I was not reassured.
In my quest for a mental trick to remember which partner was left and which was right, I repeated over and over again softly under my breath, the wife is right…, the wife is right…, the wife is right…, the wife is right…, until it dawned on me, and I shouted, “The wife is always right.”
Just then the anesthesiologist (male and married) walked into the station. “Who is right, the husband or the wife,” I posed.
“The wife is always right,” he responded, and we all laughed. He looked at the OR schedule, the chart on the desk and through the glass window to the patient in the holding area and joined in with his own knowing chuckle.
Lesson 3:
Clever mnemonics or sayings may be fun, but there is no substitute for full compliance with the Universal Protocol for preventing wrong-site surgery. Hospital Operative Site/Procedure Verification Checklists should be reviewed for 100% adherence on all cases involving laterality. Operating room leadership should give consideration to conducting concurrent direct observation surveillance of the Universal Protocol.
It was a relief to learn by the end of the day that our same-name patients’ respective surgeries were accurately and successfully completed. Now our concurrent tracing took us to evaluate their post-op course.
Our hospital’s practice is to keep orthopedic patients together. Not only is it convenient for the attending, it also allows for specialized staff and equipment to be efficiently dedicated to their care. So, consistent with our practice and at the request of the couple, these two patients roomed together. The nursing staff assigned to their care were pleased the husband and wife pair were in the same locale. They commented that by having them together it was easier to “keep them separate” since their caregivers knew both of their treatment plans, medication regimes, and patient specific interventions. However, a report from the Agency for Health Care Research and Quality cites cases of wrong patient medication and blood administration errors in situations where patients with the same name were in the same room (Shojania, 2001). As a result, a “Risk and Quality Management Strategy on Patient Identification” published by ECRI, made several recommendations to avoid making “Wrong Patient Errors” including, “implement a policy to prohibit placing patients with the same name in the same room” (ECRI, 2003).
Lesson 4:
Ensuring the accuracy of patient identification is a complex and challenging goal. A variety of strategies including thoughtful room assignment can assist in preventing wrong-patient errors. However, consistent with the recommendations put forth by that National Patient Safety Goal, there is no substitute for a comprehensive patient identification policy and procedure that requires two unique identifiers to accurately identify a patient.
As the chief nursing officer, I frequently round on the units and often visit patients. I certainly wanted to stop in on the husband and wife surgical couple. I was pleased to see they were sitting up in chairs next to one another holding hands. I was also pleased to see that same-name caution stickers adorned many items including their beds, charts, and wristbands. I mentally marveled at just how many opportunities there are to make an error and how many safety procedures our industry has in place to prevent them.
After introducing myself and chatting briefly, I realized that Mr. Knee Replacement was something of an amateur comedian, already cracking a few jokes about his surgery and the hospital. I wanted to have a serious conversation with him and his wife, cautioning them about the challenges of caring for two patients with the same name.
“The staff will be asking you often what your name is. They will be looking at your ID band constantly, checking your name and medical record number. Please don’t get annoyed with them,” I requested. “They need to do their job, and not mix you up with your wife.”
In response, the patient bent over, put his head between his knees, and peered under his hospital gown. He then raised his head slightly and grinned wide. “I don’t know,” he said. “I just checked, and they shouldn’t have any trouble at all telling the difference between me and my wife.”
I blushed slightly and laughed demurely. It was the reaction I knew he expected. The wife pooh-poohed her husband’s antics and constructively reinforced my message.
Numerous organizations, including the JCAHO, advocate that patients themselves take an active, involved, and informed role in their own healthcare. The JCAHO SpeakUp program provides literature to patients that includes advice to “pay attention to the care you are receiving.” The SpeakUp brochure states: “Make sure your nurse or doctor confirms your identity, checks your wristband or asks your name, before he or she administers any medication or treatment (Spath, 2004).
Lesson 5:
Engage patients to be knowledgeable participants in their own care. Staff should not be offended when patients remind them of the hospital’s own safety procedures. Include in policies the need to inform patients of what safety measures are taken and why, as well as to invite the patients to participate in the process.
I was pleased and relieved when these patients were eventually discharged after their transfer to the acute rehabilitation unit. They were properly cared for every step of the way. In addition, the nursing department had a chance to experience the tracer methodology, scrutinize two important safety protocols, and realize some valuable process improvement.
Several weeks later, I opened up the health section of our local paper to see my favorite patient-couple beaming for the camera. Posed at home, dressed in street clothes with orthopedic supplies in view to provide the perfect composition for the shot, the headline above read, “One new knee apiece for the pair.” The article extolled current orthopedic technology that allows arthritic body parts to be replaced surgically with artificial ones made of metal and plastic. Various doctors were quoted, and numerous health statistics cited. The husband and wife answered questions and mostly referenced their pain, rehabilitation, and long haul to a full recovery. Our hospital was not even mentioned! Nor was the fact that these two individuals were cared for successfully, without a mishap, despite all the potential risk with which our hospital was challenged. We provided them with extraordinary attentiveness and safeguards while upholding complex policies and procedures in order to protect them from error.
Acknowledgment
The author is indebted to Eileen McGuigan, RN, nursing quality assurance coordinator at Long Beach Medical Center, for her expertise managing this project and her assistance with the manuscript for this article.
Kristina A. Krail (kkrail@lbmc.org) is currently chief nursing officer at Long Beach Medical Center in Long Beach, New York. A healthcare administrator for over 25 years, she is a diplomat in the American College of Healthcare Executives and certified as a Nurse Administrator-Advanced by ANCC. Krail has been a nurse executive at several hospitals in NY, NJ, and Connecticut and was recently the COO at a regional New York hospital association.
References
DeLorenzo, M. (2005, March). Shared Visions-New Pathways: What to expect at your Next JCAHO Survey. Nursing Management36(3), 26-30.
Dobias, M. Ed. (2005, June 6). How to use tracer as a tool for change. Inside The Joint Commission,7-8.
ERCI (2003, May). Patient Identification. Risk and Quality Management Strategies #16. http://www.ecri.org/Patient_Information/Patient_Safety/riskqual16.pdf
Institute of Medicine (IOM). (2000). To Err is Human: Building a Safer Health System.L.T. Kohn, J.M. Corrigan, and M.S. Donaldson (Eds.). Washington DC: National Academy Press.
JCAHO (2005). Facts about Patient Safety. http://www.jcaho.org/accredited+organizations/patient+safety/facts+about+patient+safety.htm
JCAHO (2004). Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. http://www.jcaho.org/accredited+organizations/patient+safety/universal+protocol/wss_universal+protocol.htm
JCAHO Sentinel Event Alert (2001, December 5). A follow-up review of wrong site surgery. http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_24.htm
Shojania, K.G., Duncan B.W., McDonald K.M., et.al., Eds.(2001, July). Making health care safer: Acritical analysis of patient safety practices. Evidence Report/Technology Assessment No. 43. Agency for Healthcare Research and Quality. http://www.ahcpr.gov/clinic/ptsafety/chap43a.htm
Spath, P.Ed. (2004). Partnering with patients to reduce medical errors. Chicago, AHA Press.