Talking Points for Physicians

Minnesota Safe Surgery Coalition

·  Goal of the Minnesota Safe Surgery Coalition is to eliminate wrong-site, wrong procedure, wrong patient events within a 3 year time frame using a multi-pronged approach to engage physicians, front line staff and facility leaders.

·  Reports of adverse events involving procedures performed on the wrong site/side/level have been increasing. Last year Minnesota experienced higher numbers of wrong site procedures than ever before.

·  Wrong site surgeries can be a devastating experience for the patient, state licensure boards are imposing penalties on surgeons for wrong site surgeries, most insurers have decided to no longer pay providers for wrong site surgeries, and wrong site or wrong person procedures are held compensable under malpractice claims.

Minnesota Time Out Campaign

·  Last year (2010), over 60% of wrong site procedures were on the wrong side (left vs. right)

·  In 38% of wrong cases last year (2010), the procedure site was correctly marked but no one on the team looked for the mark before the start of the procedure.

·  78% of wrong site events last year (2010) had one or more of the key site marking or time-out best practices not completed.

·  Almost all adverse events were breakdowns in the basic best practices; primarily the Time Out, such as:

·  Site mark not visualized

·  Source documents not referred to

·  Staff stating “I agree” rather than independent verification

Call to Action for Physicians

Initiate a time out before every procedure to confirm and visualize with OR staff correct patient, correct procedure, and correct surgical site.

Step / Rationale
1. Person performing procedure initiates / The team is more likely to cease activity and come together for the Time Out.
2. Team ceases all activity / Active listening/participation.
3. Designated staff, other than person performing procedure (OR – circulator), verbally states patient name, procedure and location while referring to source documents. (In the OR, ACP also provides patient name and procedure from their documentation; scrub person states procedure set up for). / Surgeon is the last to verify to control
for hierarchy/power differential, i.e. if the surgeon states information first, the team is more likely to agree rather than provide independent verification.
Source documents have been verified prior to the procedure and should be an accurate source of information.
4. Designated staff, other than person performing procedure (OR – scrub), locates and verbally confirms visualization of site mark and states where it is located. / Providing an active role (rather than “I agree”) for all team members counters rote recitation.
Team members more likely to be cognitively engaged in the process
5. Person performing procedure verbally states procedure including location from memory. / Decreases memory interference to focus on this procedure.