After the incident last week in which a patient died after having surgery on the wrong hip, Dr. Dirk Maes wonders whether the checklist that is common for such an operation was applied correctly. Urologist Maes has been fascinated by healthcare quality and accreditation for years.
Last Wednesday, a 92-year-old woman died in the AZ Groeninge Kortrijk after she was operated on the wrong hip. It was only when the family pointed out that the wrong side was in the bandage that the mistake became clear, it said. Internal research will have to determine to what extent this is correct, but the hospital itself admits that an error occurred: not all procedures were followed correctly.
Time-out
Dirk Maes: “What really matters with such problems is that the checklist is applied correctly. In 2009, Dr. Gawande (Harvard Medical School) introduced the Safe Surgery Checklist, a standardized questionnaire that has now been internationally accepted and is also used in Flemish hospitals.”
The method consists of several phases. In preparation for an operation, the patient goes through the checklist with the patient, the same happens when the patient enters the operating room (time-out) and then you have the sign-out when the patient leaves the operating room. The intention is for the operating team to consciously consider the surgical process in which the physical integrity of the patient is at stake. It is checked whether it is the correct patient, procedure, side, etc. About 20 questions are discussed. During the preparation, a mark is already made on the side where the patient will be operated on. This sign must be visible when the patient is covered with cloths. That system is closed.
Check off
“The list itself is a perfectly comprehensive method, but the risk is that people gradually see the list only as a checklist without really consciously considering each question,” notes Dr. Maes. “In any case, during the time-out, everyone involved in the procedure (anesthesiologist, surgeon, instrumentalist, nurses, etc.) must be physically present in the operating room and do nothing other than go over the list. If the Safe Surgery Checklist is applied correctly, the process will be stopped if there is no clear answer to one of the questions. In Groeninge, people apparently passed through a hole in the system several times without the process stopping,” he suspects.
The moment the patient leaves the operating room (sign-out), it is checked whether the needles and compresses have been counted, whether the biopsy material is ready… “But there is sometimes a tendency to settle for the fact that after the procedure has been completed, that no problems were experienced. While, for example, it sometimes happens that no one knows where a biopsy taken is located,” says Dr. Maes. However, if you really carefully consider each question, such a mistake will not occur.
In any case, an incident report reveals many things that are worthwhile to avoid mistakes in the future, although reporting is sometimes still taboo for us.
Responsibility
It is also important that everyone takes responsibility in the team. “It still happens that everyone who is in the operating room is not viewed as equal. Sometimes a surgeon or an anesthesiologist shifts the responsibility to an assistant to, for example, do a ward tour during those processes. Or a nurse does not get the chance to give an error message. And then not wanting to publicize the incident if it turned out afterwards that something went wrong,” Dr. Maes outlines the problem. Although he immediately says that he is convinced that AZ Groeninge is a quality hospital. “I also know the quality manager and he often takes it very seriously. But even then, errors can still pop up. So just because the list has been checked off does not mean that the process has been applied correctly.”
Audits
He has already experienced many quality audits himself. “When I do audits in hospitals during the perioperative process, the procedure is always applied correctly in the operating room. But then I do sense to what extent that behavior has been ‘manufactured’, or whether this working method belongs to the hospital and safety culture. And whether a nurse also has the opportunity to stop the process if she thinks it is necessary. You are allowed to have these kinds of incidents certainly not due to the workload. Checking doesn’t take that much time.”
And he testifies: “I have also experienced an incident during a banal procedure – a patient’s foreskin had to be preserved even though we had removed it – where the protocol was not followed. The greatest risk is during routine procedures in the hospital. With very special procedures, the chance of something going wrong is smaller because people are usually more focused. The government must continue to raise awareness for a strong built-in safety culture.
