Dissertation Title: Is the time out policy reduces the risk of wrong procedures, wrong site and wrong patient in the hospital?
CHAPTER ONE
Introduction[M1]
Hospital management is an important factor of such operating room policies and regulations and team of physicians, surgeons, anesthesiologists as well as nurses should follow strict guidelines and for this particular research study, the focus deals to the time out policy implying correct patient and correct site of where the process should take place during surgery in which surgical process have to be successful and that malpractices should be avoided in executing of the time out policy in hospitals ( 2006). The purpose of the dissertation study is to recognize and evaluative ways of the time out policy with ample support to the literature review pertaining to the policy in focus. The review of articles is the core point of the literature study in which several cases and situations of time out policy will be realized and put into critical assessment as well as interpretation of such research methods both primary and secondary domains as there is carrying of other related topics that constitute to the time out policy as done in the OR enclosed by surgical protocol and laws. The identification of such themes that support the time out policy incurs relevance upon realizing proper hospital management. It is a must to investigate further on the time out policy as it can be amiable that certain incidence of OR malpractice and miss outs have to be prevented by following time out policy in the hospital as touching the wrong body part for instance, in the actual operative process is a major case in which it cannot be easily be mended from within in responding to certain righteous actions inside the OR so that malpractice in the actual surgery maybe reduced and prevented and the involved patients have the confidence that their operations is safe and sound. The articles will then have to emphasize the role (on patient safety, 2002) which is premiere to the time out policy as it will help OR team in action to be composed and more focused not to commit mistakes on the patient, this notion are supported case studies in which OR team in action to be composed and more focused not to commit mistakes on the patient, this notion are supported case studies in which such wrong site surgery happens and it is painful on both sides of the matter. Indeed, article evidences show that time out policy reduces risks in undergoing surgery measures and procedures as found within the grounds of the operating room. Aside, further research investigation on the time out policy should be put into a broader context that are accepted by medical authorities and implemented into the general laws of the hospital such as the Hong Kong Hospital as an example. The research should aim to determine effectiveness of the time out policy from within the OR setting and is duly backed up by professional studies from within the medical field and from within the hospital organization. The recent findings of research does impose reliable advantages to the OR team as composed of surgeons, nurses and other involved personnel mostly, to the patients’ family and to the patient himself from which certain issues have to be tackled and recognized in an informed perspective ( 2006).
Then, every hospital institution should have a policy and procedure that incorporate certain of hospital rules and will have to ensure that any valuable requirements for patient identification as well as site marking and pre-operative/pre-procedural verification, mostly the policy adhering to ‘time out’ are being systematically followed whenever certain invasive procedures are performed but not limited to procedures performed within the operating room, emergency departments and other areas in the hospital. It is critical that certain hospital policy and procedure must specify the detailed actions to be taken wherein such discrepancy may occur anytime into the process ( 2003 , 2002). The other good purpose of this dissertation study is to be able to define the requirements of pre-procedural verification, surgical site verification with specification and the time out policy for final verification of correct site and patient. This helps to ascertain that time out policy reduces the risk of wrong procedures, wrong site and wrong patient in the hospital ( 2003 in,, 2002). Then, in order to go on with further investigative study centering on the topic focus, it can be vital to define such terms (please refer to appendix one) and that there is simple example as can be found within surgical cases as there must assume operative standards from within process of verifying the right patient, as well as the site in which surgery should be done, entailing to the correct part for the operation to take place as geared towards consistency of the process and that, the policy of time out has to be recognized to gain success of the action taken. Furthermore, it is important to realize and have knowledge to such steps that goes in with the time out policy law in the hospital like for instance (see below points): ( 2003 in, , 2002).
- The physician will verify the surgical procedure with the patient or legal representative at the time of planning for the procedure
- Preoperatively, each procedure involving laterality will be scheduled with right, left, bilateral, or other required designation through the normal scheduling process for the procedure
- The physician will document the planned procedure, with the correct site in the patient’s medical record using the word left, right and other terms
- The surgical consent form will identify the specific planned procedure, with surgical site, as appropriate as possible
- A Registered Nurse will confirm the correct surgical procedure and site through
- Further, patient or legal representative will be asked to identify the planned surgery, including laterality, digit or level, if appropriate
- Review of the surgical consent document noting the correct procedure and site
- Review of the scheduled procedure, including site, as appropriate, for procedures noted on a written schedule
- Obtaining all relevant imaging or other reports and reviewing of these documents for consistency of surgical procedure and site
The importance and significance of the time out policy incurs research investigation and literature understanding of such applications and weight of the time out policy as important for this study as the core function of time out policy is to ensure patient safety at all times, in every situation especially under operative procedures found within the operating room, time out policy is being backed up by patient safety and upon ensuring that safety is a top priority within hospitals there fits time out policy effectiveness from within policy integrity and substance. According to research found in the emerald insight database, it can be that “ppatient safety and medical error have become prominent issues following publication studies path that uses language rejected by the interdisciplinary group of experts described previously in this column, and continues using methods considered seriously flawed as well as incomplete by noteworthy hospital staffs. Preliminary review of British hospitals by similar methods also has been published as there enumerates such patient outcomes and attribute and OR error can be avoided and time out policy is one of ideal alternative option to follow and mistakes are reduced then” ( 2002 ).
Truly, time out policy within this research plays weight into the topic relevance from within literature as the time out policy is believed to incur rigorous control on such patient claims that are too lengthy and will affect the principle of the Hong Kong Hospital for example, this policy assures that correct actions were executed amiably within the hospital grounds. Indeed, literature shows certain safety problems if time out policy is neglected within the health care in Hong Kong and in genera as better patient safety depends on better data about time out incidence from routine monitoring for timely action ( 2004; 2003; 2003). The healthcare providers have to be obliged to have time out as a medical policy and without having to prove negligence. However, statistics show hhigh proportion of patient management errors, 58 percent of OR adverse events do suggest that surgical events would be preventable if the policy is followed in every process ( 2001). Then, (1999) have found evidence that malpractice lawsuits could be prevented by safety interventions within time out policy and guidelines adaptation. The risk of OR surgery errors can never be eliminated even if time out policy is utilized but such risks knowledge do provide the OR team ideal opportunities for improving OR quality, having assumption driven approach found within the time out policy context from within by patient safety assurance and realization.
Thus, effective communication is essential when verbalizing correct surgical site and applies to all instances of affirmation. Saying the word “correct” is to be used when verifying the surgical procedure/site. Example of an ‘Active Time Out’ – staff in the room stops what they are doing and participates in the final verification. “Time out” immediately before starting the procedure is to be conducted in the location where the procedure will be done, just before starting the procedure ( 2003 in, 2002). It is to involve the entire operative team, use active communication and can be briefly documented to have the:
- Correct patient identity
- Correct side and site
- Agreement on the procedure to be done
- Correct patient position
- Availability of correct implants and any special equipment or special requirements.
It is then essential if for instance, there is inconsistency to the time out policy and the physician/surgeon performing the procedure and the appropriate clinical staff member in the procedure area will be notified immediately. Thus, marking of the surgical site in not required when the site is so clearly evident that is can not be confused for example, traumatic open fracture of femur, technological markers may be used instead of initials to mark sites. Aside, for cases that require site marking, if the practitioner performing the procedure remains with the patient continuously from the time the decision is made to do the procedure and consent is obtained from the patient up to the time of the procedure itself, then site marking is not required. However, if the person performing the procedure leaves the presence of the patient for any amount of time during that interval, then the site should be marked. When invasive procedures are performed under emergency or urgent conditions, the practitioner performing the procedure will be in continuous attendance of the patient from the point of decision to do the procedure.
Research Aim and Objectives[M2]
This particular research aims to understand briefly about time out policy and aim is to recognize policy assurance wherein there needs to have better level of patient safety such as within nursing staff as they will positively identify patients who are delivered to or transported from hospital units assuming the correct patient. The use of SMART objectives for this research can be adopted into the content in which importance of the literature review will be understood from every side of identifying OR time out policy in its underlying developments. There should be good planning and the setting in objectives through SMART strategy as it means (Specific, Measurable, Achievable, Realistic and Time-Bound). The need to find out better actions on how to fully execute the time out policy in the hospitals within a specific context involving hospital staff like those within the OR area. The use of case study and surveys should be evident in the study and should be realized from within week’s time prior to the study giving enough time to gather useful and appropriate resources that links to the literature review as analyzed and presented and determining of time out policy if being recently adopted within the medical surgical area of the hospital, investigating situations relating to the policy in focus and the goal of motivating authorities to follow rules should be known at hand as backed up by valid secondary resources like, cases reports implying to time out policy as well as related journals and articles. The conduction of survey can be an effective tool for the study to be in real shape and have a realistic assumption and put it into feasibility option in which procedures and measures have to be followed accordingly such as how the case study will be presented at the same time assessed and how surveys are to be administered thus, it have to be in questionnaire format that poses questions that are structured and how it be created, for this research, semi structured and open ended questions can be ideal to know and understand perceptions, views of the OR team regarding time out policy mostly, the surgeons and the anesthesiologists thus, comparing and contrasting of literature points through comprehensive article analysis and case interpretations have to be in conformity with the research focus and that obtained measure techniques most be known both quantitatively and qualitatively upon encouraging interim research paradigm by knowing achieved research objectives. The process then, has to be time-bound from within time frame into necessary research action. The research will be complete in two months as possible as such surveys will gather points for determining rightful approach such as those finding evidences supporting time out policy literatures, the below diagram shows how SMART objectives are connected to each other into the process of application and research vigor. There is initially execution of effective research methods as essential within the literature studies comprising of valid resources in determining that the OR time out policy truly reduces risk of procedures, site and or the patient identity before certain surgical operations take place.
SMART Objective Cycle
Source, cited from: Learn Marketing: SMART Objectives
Retrieved at:
Research Questions[M3]
Research questions are important factors in understanding overall process of the dissertation study mostly, with regards to comprehensive assessment of reviewed academic studies manifesting literature effectiveness that can be supported by research articles and cases pointing to time out policy.
CHAPTER TWO
LITERATURE REVIEW [M4]
Introduction
Good review for the literature study plays an imperative function for every research to achieve reliable and valid research findings as well as study outcomes as reviews do give comprehensive data within underlying resource and materials that combines both quantitative and qualitative truth within the topic relevance upon ensuring intellectual skills, through choices of academic documents as being written from a desirable standpoint. The literature review does provide assessment of research studies in such articles and journals relating to time out policy and such issues as recognized like from JCAHO cases and AORN evaluation. Literature points out time out policies amiably strengthen patient choice in OR care as observes that patient satisfaction surveys and the like are of little practical use when OR team have the discretion to ignore policy outcomes ( 1994,).
The effectiveness of the research investigation assume positive influence and reinforcement catering to time out policy as focused such as determining of hospital needs of the individual patients coming from surgical operation from a wider base of health needs of hospital patients found in the OR area for operative measures as determined by the hospital health service as the time out policy should be well attended into handling better OR management for recognizing safety measures and success within safety patient. There needs to have detailed and well organized literature review as research evidence are indicated and properly manifested as linked towards research aims and questions in focus upon providing the readers substance knowledge medium in helping the time out policy to be known to the general public so that surgical errors will be reduced and that such risks involved in wrong site surgery, measures and procedures can be terminated as the research studies will give ample support to the core issues and themes presented forming a valid discussion analysis pertaining to time out policy in hospitals particularly in the side of OR measures ( 2004). There has then, developing of knowledge domain to understand certain time out policy cases such as time out miss outs pointing to factors and evidences linking to wrong site surgery in which the surgeons and anesthesiologists touched the wrong body part from the point of surgery upon the fulfillment of studies as investigated, and gives the readers precise awareness of the time out policy mostly in the Hong Kong setting and where to find out databases for searching peer reviewed journals and articles from such study acquisition like, recognizing factors that affect time out policy mistakes in case of identifying a wrong site surgical application according to the Institute of medicine for example, some cases of wrong-site surgery have gained considerable attention and can be extraordinarily devastating to patients, families and institutions (cited in, 1999; 2001; , 1998) The wrong-site, wrong-procedure and wrong-patient operations often occur because of failures in communication and collaboration, the has identified communication breakdowns as the most common root cause of wrong-site operations and of operative and postoperative events in the year 2005 (Cited in, 2004;l, 2004) The use of briefings as structured coordination opportunities has garnered a lot of attention in recent years, yet we know surprisingly little about operating room briefings as means to decrease the risk of wrong-site operations (cited in,, 2006; , 2006) But, the wrong-site surgery has been rare since the stop moment – time out policy has been promulgated to be another law for hospitals to follow which adheres in safeguarding patient safety although, there may be difficulties in evaluating OR ways and effectiveness of treatment as designed to avoid cases of wrong-site surgery. This research study gives significance to the literature upon pointing in of time out policy evaluation in minimizing wrong cases of surgery measures and lessen risks into the OR field as literature incurs policy checklists as well as assessments of the policy from the perceived risk of surgical events.
Literature evidence suggests that there is significant value in conducting a preoperative discussion just before skin incision at the time of a surgical “time-out” to briefly review the names and roles of all team members, the operative plan, the familiarity with the procedure, and potential issues for the patient ( 2006; 2003). The aim of this study was to measure the association between OR briefings and clinician perceptions of collaboration and perception of risk for wrong site surgery. The evidence that using OR briefings significantly reduces uncertainty about the location of the surgical site among OR caregivers. In addition, OR briefings are effective tool in promoting teamwork between anesthesia and surgery staff members and in more fully using input from relevant caregivers for decision making in the OR ( 2006; , 2003). The literature study in brief can have significant impact on improving care coordination and reducing the risk of wrong site operations in the OR will serve as valuable tool to evaluate the effectiveness of interventions to improve patient safety and collaboration in the OR. Ideally, one approach is to use an education model in which knowledge leads to changes in attitudes by which changes behavior and ultimately reduces preventable harm as knowledge of new practice to improve safety is an essential first step in the prevention of harm. It is important to train health providers about implementing intervention and to measure the effectiveness of training with knowledge assessment. Then, through utilizing certain surgeon/physician champion in facilitating development of patient safety can be a good option in changing the attitudes toward OR safety in hospitals centering on the stop moment before doing the case ( 2006; 2003).
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MODEL FOR HARM PREVENTION
Source, adopted from: 2007),
Indeed, articles from the year 2006 up to the present asserted that, it is basically true when knowledge and attitudes toward safety interventions are aligned, it is still important to investigate whether these translate to the adoption of desired behaviors in practice. Certain process, if implemented well can provide predictable and structured feedback related to routine practice. More research is needed to further validate this model and the associated data collection methods, so that OR patient safety efforts are evidenced based and conclusion able. The OR briefing as safety initiative designed to reduce wrong-site surgery has many implications in physician and nurse training. Incorporating the OR briefing into residency training for surgery and anesthesiology residents, nursing training and medical student training may prove beneficial in improving care coordination and reducing the incidence of wrong-site within surgery ( 2000; 2000).
In addition, integration of briefings into medical and nursing education may help improve the teamwork climate in operating rooms by promoting consistent and structured communication, proactive planning for potential problems and interdisciplinary collaboration between physicians and nurses in surgery and anesthesiology. Briefings before procedures may also be valuable in reducing adverse events in the outpatient setting even though briefings are not panacea for what ails care coordination in health care, they do have the potential to fill many of the gaps created by production pressures, staffing problems and the lack of familiarity with the environment as well as procedures ( 2001)
SOS TIME OUT (Stop Moment)
Immediately prior to commencement of surgery the surgeon, anesthetists, and the scrub person should undertake a time out to verbally confirm the intended Site, Operation, Side and identity of the patient checking this information against the patients identification bracelet, the operating list and the consent form/patient health records. It is the scrub person’s responsibility to document confirmation that this time out has taken place within the patients’ theatre record.
RELATED STUDIES SORTED FROM RELEVANT ARTICLES/JOURNALS
According to research, one more wrong-site surgery event has been reported for the fourth quarter of 2007, increasing that number from 13 to 14, and 18 events have been reported for the first quarter of 2008 as 5 of the 18 were limited to punctures of the skin for the injection of local or regional anesthesia preparatory to the scheduled procedure, still wrong-site surgery as defined by the National Quality Forum (cited in, 2006; 2004; 2000). Detailed wrong-site surgery reports continue to be submitted by cooperating facilities in follow up to reports of near-miss and actual wrong-site events. By comparing the processes that were and were not significantly associated with trapping the error before harm occurred, PA-PSRS clinical analysts can better understand which processes are associated with successfully catching these rare events (cited in,2006; 2004; , 2000).
As of 2008, such cumulative total of 70 results from in-depth surveys about near-miss events and a cumulative total of 28 results about actual wrong-site surgery events from 62 cooperating facilities have been received through PA-PSRS. The compliance rate with the request for detailed information within 30 days of the event has been more than 75 percent (cited in, , 2006; , 2004; 2000). In the update, reports of near misses were significantly more likely to indicate the following:
- The time out was done after the patient was draped
- The surgeon’s records and diagnostic images were available in the operating room
- Diagnostic tests were reviewed by the surgeon before the incision was made
- The patient’s identification, the procedure, and antibiotic administration were addressed as part of a preoperative briefing with the surgeon.
Thus, verification by the patient of the information in the documents was always done in the wrong-site surgery events, but not always done in the near-miss events. It is possible the near-miss reports that indicated a lack of verification intended to convey not that the patient was excluded, but that the patients’ responses did not agree with the written information.
The Application of Three R’s
“Generally, hospitals take time out to verify the right site, right procedure and right patient as part of multidisciplinary safety campaigns and accordingly, last July, the surgical teams in -accredited hospitals, ambulatory care and office-based surgery facilities are required to take moment before the first cut and make sure that the team is operating on the correct patient and doing the correct surgery on the correct body part. The preoperative verification, marking of the site, and the time-out, which immediately precedes the first incision, are required elements of the Universal Protocol. The protocol also is intended for any invasive procedure, whether it’s in surgical suite, emergency department, as wrong site surgery is basically unforgivable and Universal Protocol will prevent these surgeries from happening and that one of the biggest challenges is getting beyond the concept of regulation and compliance and really driving patient safety agendas that are unique and specific to individual organizations” (cited in, August 2, 2004 from: The surgical team has successfully incorporated this process into the operating room work flow. Development of a process has increased awareness of these measures and has helped achieve standardization across multiple campuses and surgical areas. There is then, a systematic approach toward safety measures can improve compliance. Incorporating additional measures into the Time Out to identify correct operative site has allowed our facility to improve application and timing of the procedure.
AORN’s Evaluation
AORN is evaluating the Universal Protocol to establish what factors promote the use of the protocol, as well as which factors serve as obstacles to its execution. There will be a second summit on wrong-site surgery held later this year, during which the results of the evaluation will be offered for discussion. The reason for the evaluation is that these sentinel events may still occur, and not all medical professionals are instituting the time out as is recommended. MSN, CNOR, of Massachusetts General Hospital, and a preoperative education consultant for AORN, will be performing a dissertation study on the results of the Universal Protocol, and will also evaluate the effect of the AORN Correct Site Surgery Tool Kit on implementation of the protocol. “With any new protocol, it is critical to evaluate its effectiveness and how well it supports practice,” observes. “The Universal Protocol is supported on the intellectual basis. However, in practice, distractions can occur, and there is only one recent study ( 2006) about it, which suggests that the Universal Protocol is effective in approximately two-thirds of the cases of wrong-site surgery. Since the protocol is not always being followed, AORN wants to ascertain how to get physicians, nurses, and other healthcare workers to fully observe the Universal Protocol. The association is not in a position to enforce compliance, points out, “They can recommend practices based on research and standards and encourage members to follow them. In addition, they can provide supportive materials to members, as in this case — the have an obligation to read and follow the best practices every day.”
Site marking should be done by the person performing the procedure, and must take place with the patient awake, aware, and involved. There must still be a final verification of the site mark during the time out. In addition, the healthcare facility should have a defined procedure in place in case a patient refuses site marking. The time out must take place in specific locations and at multiple times, according to the protocol. It must be conducted in the procedure area just before the surgery begins, and must involve the entire operative team. At a minimum, it must be documented, involve active communication, and must include a correct recognition of patient identity, side and site of surgery, and procedure type, as well as correct patient position and availability of required implants and special equipment or requirements for the procedure.
There should also be a system in place for resolving differences in staff responses during the time out.
If there is a non-OR setting being used for the procedure, then the following procedures apply:
- Site marking for any procedure with laterality, multiple structures or levels
- Verification, site marking, and time out procedures that are consistent throughout the facility
Wrong-site surgeries – still happening
The majority of mistakes occurred in orthopedics and involved surgeons operating on the body part, such as in the highly publicized Willie King case that quickly became the national poster-story for wrong-site surgery. In 1995, went into a Florida hospital to have a foot amputated for gangrene, but surgeons amputated the wrong foot. In another mishap, a Rhode Island surgeon cut into the wrong side of a patient’s head after a CT scan was placed backward on the X-ray viewing box. According to , the growing numbers of surgery mistakes are most often caused by a breakdown in communication among surgical team members and the patient and family. Many of the mistakes are made in emergency cases, or where there is an unusual time pressure or set-up in the operating facility. Lack of hospital policy safeguards such as requiring the marking of operative sites and verification checklists have also played a key role. Most experts believe the new rules will help to make operating rooms safer for patients, but that there is no way to completely eliminate human error.
Time Out for Patient Safety
The is taking a Time Out to offer some suggestions to patients to help prevent wrong-site surgery and other preventable surgical mistakes for people having aesthetic plastic surgery. For ASAPS, honoring Time Out Day is part of the Aesthetic Society's Campaign for Patient Safety, an ongoing initiative to raise awareness of the steps that plastic surgeons and their patients can take to make cosmetic surgery safer. The Society's first campaign issue was focused on the prevention of venous thromboembolism; the second initiative was about prevention of hypothermia during surgery. The surgical time out, including active communication among the surgical team, final verification of the correct patient, and marking of the operative site, help your board certified plastic surgeon make your surgery as safe as possible.
Wrong-site surgery is a devastating problem that affects both the patient and surgeon and results from poor preoperative planning, lack of institutional controls, failure of the surgeon to exercise due care, or a simple mistake in communication between the patient and the surgeon.
Patient Safety in Surgery – Current IssuesComplications due to individual surgeons' errors and system failures are inherent in surgical practice and represent important preventable causes of morbidity and mortality. In spite of the increasing public attention to medical errors in general, a new level of transparency for consumers, and the current trend to process preventable adverse events systematically, surgical complications appear to represent a persistent taboo throughout different countries and institutions. One would assume that a patient scheduled for a surgical procedure would expect to be better off after the intervention than before. However, while physicians strive to achieve excellent results and favorable patient outcomes in daily practice, this noble task has failed more often than one expects.
Preoperative Communication Breakdown
A recent analysis of the American College of Surgeons' closed claims study revealed that most events leading to iatrogenic patient injuries involved a delay in diagnosis, a failure to diagnose. Thus, patient safety in surgery appears to be challenged more by the mistakes and failures that occur before and after surgical procedures than by the operative intervention itself. Interestingly, technical intra-operative errors resulting in surgical complications represent less than half of all events leading to a claim. Indeed, about 25 per cent of all medico-legal surgical claims related to errors leading to an adverse patient outcome are attributed to a per operative breakdown in communication. Thus, the surgical patient appears to be more at risk of sustaining an adverse outcome from hidden system errors than from an individual surgeon's human failure. A detailed analysis of communication breakdown patterns revealed an equal distribution of occurrence during the pre-, intra-, and postoperative phases of surgery. More than 90 per cent of communication breakdowns appeared to occur verbally. Of these, information was either transmitted in an inaccurate fashion (about 40 per cent of cases) or it was never transmitted at all (about 50 per cent of cases). Similarly, the Malpractice Insurers Medical Error Prevention Study recently provided information related to trainee involvement in medical errors. Teamwork breakdowns in the form of (1) a lack of adequate supervision and (2) "handoff" problems were causative in 70 per cent of all errors leading to malpractice claims (Source: 2007).
An adequate approach for improving "communication safety" in the operating room should include the implementation of standardized "read backs" of received information, and the unambiguous assignment and transfer of responsibilities. These strategies have long been implemented in other high-risk domains, such as nuclear reactor control rooms, submarine services and commercial aviation safety protocols. In clinical practice, clear-cut algorithms should define triggers which mandate the communication with an attending surgeon ( 2007). Furthermore, standardized protocols for patient handoffs and transfers should be defined at the institutional level. Written orders and checklists should support inter-individual verbal communication, including the count of lap sponges and surgical instruments, in order to reduce the incidence of adverse events related to communication breakdowns in surgery. Currently, the development of specific communication skills is underemphasized in residency programs and may contribute to the missing system factors, which beget poor results of patient care.
The concept of a surgical "time-out"
Any intervention involving a wrong site (wrong side / wrong level / wrong anatomic structure), a wrong procedure, or a wrong patient, represents an unacceptable surgical complication "never-events" (Table 1). A lesson learned from aviation safety is that a "culture of blame" approach for dealing with individual surgical errors is not helpful in improving patient safety or reducing the incidence of severe complications. On the contrary, wrong site surgery represents a "classical" system error rather than pure human failure by an individual surgeon. Ten years ago, this notion led to the implementation of a standardized surgical "time-out" in North America as an improved method of verifying patient identity, correct procedure and intended-site operations. Since then, the concept of a surgical time-out has been widely implemented in operating rooms throughout the US and represents a standard recommendation by the . A culture of zero tolerance for "never events" is a key to keeping patients safe. From a patient safety perspective, the fact that this surgical time-out paradigm has not yet been implemented as a standard of care in most parts of the world appears incomprehensible and ethically unacceptable. Of note, the time-out concept can never be 100 per cent protective from wrong site interventions. Potential loopholes in this system include relegating the time-out to a robotic hackneyed type ritual or the continuing "dilution" of the time-out by expanding to secondary safety issues, such as antibiotic and venous thromboembolism prophylaxis, as implemented in the so-called "expanded surgical time-out" or "universal protocol". The use of the formal time-out as a quality control tool for secondary parameters may deflect from its original purpose of ensuring correct site, correct procedure and correct patient surgery. Another risk factor for wrong site surgery is represented by the situation of multiple simultaneous procedures performed during the same surgical session. This is exemplified by the case of a patient undergoing multiple surgical interventions for different injuries, thereby obscuring the focus of the time-out on a particular operation. In addition, some specific anatomic locations may represent "black boxes" during the time-out, and thus represent a particular risk for wrong site interventions. These include orthopedic procedures at the torso, dental surgeries, neurosurgical interventions, and intra-abdominal or intra-thoracic operations. For example, an orthopedic surgeon may perform a sacroiliac screw fixation on the wrong side or fuse a wrong inter-vertebral segment of the spine.
Recently published studies indicate that wrong-site / wrong-procedure / wrong-patient surgeries surprisingly continue to occur in North America. For example, adverse event data from the state of Florida, US, reported 178 wrong site, 82 wrong procedure and 34 wrong patient cases for the years 2000-2003 ( 2006). A detailed analysis of certain extensive database at the Colorado Physician Insurance Company (COPIC) on 20,775 physician self-reported complications, we detected 99 cases of wrong-site surgery and 20 cases of wrong-patient procedure in the years 2002-2007 ( unpublished results). The persistent occurrence of these "never-events" in the era of a surgical time-out may be explained by individual surgeons' non-compliance and by numerous pitfalls related to accurate surgical site determination, as outlined above. Also, the time-out should not absolve the individual surgeon from taking full responsibility in ensuring by all available means that the correct procedure is performed at the correct site on the correct patient. All institutions have to now consider adapting a formal time-out concept as a standardized quality assurance tool. Patients must be educated to inquire their surgeons whether a formal time-out procedure will occur in the elective surgical suite.
Reporting of medical errors in surgery
Systematic medical errors represent an essential "information problem". While the intellectual argument for reporting medical errors in surgery is compelling beyond a doubt, surgeons remain inherently reluctant to disclose surgical failures and complications in public. The main barriers for reporting surgical errors are based on the fear of medico-legal lawsuits, potential loss of professional prestige among peers, and the well-engrained tenet of non-admission of guilt and fallibility among surgeons ("blame and shame culture"). In this regard, the major ethical concern is that the suppression of data on surgical errors will deprive other surgeons of adequate scientific knowledge, which may help prevent identical errors in the future. In contrast to aviation safety, where the implementation of systematic error reduction policies has led to an irrefutable, impressive drop in fatal accident rates in the past decades, surgeons remain reluctant to recognize, analyze, and officially report their own errors. The "human factor" which may help explain the discrepancy between the situations in aviation versus surgery is based on the fact that a pilot is usually killed with a crashed plane, whereas a surgeon suffers no personal physical harm from a patient's complication. Thorough reporting and peer-review of surgical errors creates a new dilemma for the surgeon in practice: an increased quality of reporting leads to an increased official number of complications and adverse events, thus affecting the individual surgeon's professional track record and the respective institution's ranking among peers. Until legislation provides legal protection for medical error disclosure and analysis, we continue to rely on the inadequate reporting of errors and complications in the peer-reviewed biomedical literature. A recently launched open-access online journal, Patient Safety in Surgery , was designed to complement traditional journals in surgery by filling this essential void, through providing a forum for discussion, review, and "root cause" analysis of failures in the management of surgical patients. This scientific forum should create a focal point for critical discussion of surgical errors and lower the threshold for reporting adverse events in all fields of surgery. As a result, the long-term goal of increasing safety and quality of care for patients undergoing surgical procedures will be effectuated.
CHAPTER THREE
Research Methodology
The time out policy research is to be conducted in order to evaluate such policy that centers on the compliance involved within the process as substantial factor upon answering specific research objectives and questions. There will be a total of one hundred respondents comprising of surgeons, anesthetists and nurses as randomly selected to make up the research sample as the selected participants will be answering a survey questionnaire within Likert format.
Method Design
Descriptive method of research was used as (cited in, 1994) stated that the descriptive method of research is to gather information about the present existing condition. The emphasis is on describing rather than on judging or interpreting, this method allows flexible approach, thus, when important new issues and questions arise during the duration of the study, further investigation may be conducted. The primary data have to be derived form answers the participants will give during the survey process. The secondary data on the other hand, have to be obtained from published documents and literatures that are of applicable relevant to the study (cited in, 2003).
Research Instrument
The study use survey questionnaires to gather pertinent data. Moreover, the researcher also uses previous studies related to the current situation of time out policy and such issues relating to wrong site surgery and other factors as there needs such critical analysis within the existing data upon providing ideal conclusions and competent recommendations. The questionnaire will be distributed in the OR department of the hospital. The questionnaire has to be easily structured by means of using the Likert format within such response scale (cited in,1990); 1998) points and below can be the designated quantifications to be used within the questionnaire:
5
Strongly Agree
4
Agree
3
Uncertain
2
Disagree
1
Strongly Disagree
Interviews
Several effective Interviews provided an in-depth illustration of the promotion of effective time out policy and its compliance in certain operative and surgical situations and thus, the respondents of the study such as surgeons and nurses will be the main factor for the survey i8nterview success. The interview serves as the primary tool in providing clarification as well as verification of the survey outcomes to be executed upon proper conduction. The semi-structured interviews were carried out within the interviewees as compared to structured interviews which are standardized and do not allow the interviewer to deviate from survey questions (cited in, , 2003), utilizing of open-ended questions have to be in usage points as open questioning will help the researcher explore more on time out policy and will be aware of complete account to such cases happening from within operative and or surgical procedures as the survey interviews will have to be conducted in proper and valid pacing of the survey (cited in, 1990); 1998) The research methodology and design process would involve such primary as well as secondary sources for bringing about a substantial studies that are literature based and theoretically inclined for which such research methods utilized may truly serve its first hand purpose for this study. The primary sources will have to represent original thinking of medical professionals that denotes ample time out policy information as core data for the research. There should also be integration of secondary data as findings and assumption studies made by researchers as a good option that supports any valid information as explored by the indication of research strategies in motion. The study procedure must be explained to the participants and reassurance notion must be made to them like their answers will be taken in anonymously and that their answers will remain between the participant and the interviewer. The primary data will be consisted the answers to the questionnaires of the samples while secondary data will be consisted the research done by the researcher including interviews held to compile pertinent information about the problem of the study. Quantitative and qualitative data will be analyzed. Quantitative will be sourced to the primary data gathered and will be in percentages and determination of time out policy and such indication of wrong site surgery for instance upon which certain research relationships are present and application of qualitative data will come from the open-ended questions in the questionnaire that will reflect the personal opinions of respondents.
CHAPTER FOUR
Discussion
Ideally, research outcomes determine the essence of trust into the time out policy as the putting of trust in realizing of time out policy in hospitals plays a crucial role in reducing cases of wrong site surgery, wrong procedures and wrong patient and it can be that, few developments in healthcare policy and practice have prompted careful appraisals of the importance of trust within the OR health contexts (, 1996; 2004; 2004; Hall, 2005; 2005). The time out policy adheres to the effectiveness of patient safety into surgical domains under certain laws presented by the hospital. Indeed, the policy imposes an increase awareness of the scale of harm associated with policy error in OR care, innovative emphasis with time out policy and management activities on issues relating to patient safety and significant changes to health care that are being wrought in order to reduce iatrogenic harm raise a number of issues in relation to trust.
Development of Patient SafetyIt has long been recognized that patients are sometimes harmed by health care professionals, and there have been several high profile examples of this (and of the failure of health care systems to prevent it) in the media in recent decades. In UK for example, shocking stories about a pediatric heart surgery team with very high mortality rates (, 2001), a gynecologist who caused substantial morbidity to the women on whom he operated ( 2000) and series of murders committed by a nurse (, 1994) and a general practitioner (, 2002) have attracted extensive publicity.
Until recently, it was widely assumed that harms in the context of health care were rare and either unavoidable or attributable to the incompetence, malice or negligence of a few individual health professionals, the so-called “bad apples”. There was thus little stimulus to investigate and address the problem of harms occurring in the course of health care ( 2002). In influential account of medical error, (1994) explained how the culture of medicine mitigated against the development of effective error prevention systems. Medical training emphasized the need for doctors to strive for perfection and regard themselves as responsible for patient outcomes. Doctors got the message that mistakes were unacceptable and that they should be infallible combined with the threat of damaging malpractice litigation, led them to cover up their mistakes, so that even if they as individuals learnt from them, the learning was not shared. recognized that many safety problems in health care arose as a result of the complexity of health care delivery systems. He recommended that efforts to identify and investigate errors be made routine and that health care delivery systems be redesigned to reduce the likelihood of errors by reducing reliance on human memory and standardizing processes and to increase the chances of intercepting errors before they cause harm by ample checking procedures.
The time out concept were taken up in some initiatives to improve care safety, and were moved into mainstream thinking about health care quality with the publication of the Institute of Medicine's report, to err is Human (, 2000). The report emphasized the scale of the problem of errors and harms in health care and the fact that OR problems were attributable to features of patient care and expanded level of conversation and concern about patient injuries in surgical process” ( 2005). In health policy circles, the dominant time out view entail that potentially avoidable harm is caused to patients by problems that arise during OR lapses and mistakes occur even when OR team are highly motivated to secure good outcomes for patients under surgery and highly knowledgeable and skilful in the OR measures.
The, the awareness of medical errors will undermine public trust ( 2005; , 2006). The precise nature of time out concern is not always known but may involve some thoughts: that publicized estimates of time out scale may be exaggerated such as if patients experience surgical errors and believe reports about them even if justified, can have unwelcome consequences (., 2005). Contemporary understandings of patient safety draw attention to the importance for time out effectiveness of OR outcomes not only of actions of the OR team but of their ethics standards put into practice, there incurs time out law and policy relating to informed consent as it now clearly require health professionals to inform patients about the risks as well as the benefits associated with any specific health technologies offered be4fore the surgery will start. The recognition of time out importance in relation to patient safety issues suggests that it is important that patients are appropriately informed about any significant risks to which they may be exposed by virtue of using ample OR care. However, it is likely to prove difficult to secure consensus about the circumstances in which a safety/vulnerability warning should be issued and about how to ensure that it is heard only when it is current and applicable. The requirement for time out honesty about safety issues applies not just to communication with people before and as they use health service ( 2003; 2003). Research to the policy is now needed to examine whether and how the policy checklist may be affected by awareness and consideration of different types of uncertainty and risk associated with patient safety issues and by the way information about OR care safety problems and efforts to reduce time out risks is communicated within the hospital domain. OR patients who trust health care providers will not necessarily be unable to be safety conscious and to contribute to their own safety as they use health services. The attempts to measure time out policy indirectly do not imply inappropriate associations, for example between operative procedures and perceived safety of OR surgical systems and some behaviors like the passivity of patients, the range of policy factors that may impinge on OR team relations and safety issues in diverse surgery scenarios.
Causes of medical errors and adverse eventsTraditionally, when adverse event occurred in a hospital setting, the most common reaction was to blame a person (2004). In fact, common cited cause of medical errors and adverse events is human error ( 1999;, 1994; , 2001; 1995). Thus, prior to the (2001) Report, most efforts to reduce errors and improve patient safety focused on miss outs by hospital team rather than facilities involve. The compelling evidence now suggests that the majority of errors and adverse events more accurately stem from complex chain of events that collectively contribute to the cause (., 2002; 2002). By tracing time out shortcomings that caused such OR adverse event and making systematic changes, as the Hong Kong hospitals can prevent the same error from recurring.
Time out policy error may refer to an error occurring because of deficiency in OR management system (1995). In fact, there is an implicit relationship between time out policy and human error and may increase the likelihood that a surgeon will make an error if not noticed immediately or without time out, stop moment before the procedure will start and prevent ways from being corrected before time out harm has been done to the patient at OR ( 1994; 1999). For example, sometimes nurses are taken from one unit to shore up a short-staffed unit in another part of the hospital wherein there requires OR attention as the ultimate problem of errors in health care is not about bad or incompetent employees (Institute of Medicine, 2000). There was a survey done by (2003) sampling anaesthetists’ attitudes towards OR safety found that poor communication were cited as one source of surgical error and that surgeons and anaesthetists saw time out moment is a vital factor for operative success and have increased and improved OR communication after the STOP moment (, 1998; ., 1999; Sexton et al., 2000; and 2001). Then, time out information on adverse events must be captured and recorded in such a way that it forms a basis for reflection on practice and not for defensive rationalization. This suggests strategy for sensitive collection and reflection on such information that provides narrative accounts of incidents focused on OR issues that are not picked up through time out policy review as analyzed by OR experts as gathered through data-grounded research technique, survey questionnaires and interviews.
REFERENCES
APPENDICES
Appendix One: Definition of Terms
- Laterality involves pertaining to a side of the body. Laterality is the word used by and others to relate to the side of the body such as left or right as laterality is the usual site designation, site designations are also necessary for multiple structures
- Pre-procedural Verification refers to the process of reviewing all available data to verify the accuracy of the anticipated procedure. This includes the patient’s or family understanding the planned procedure
- Site Verification incurs the physical initialing of a site of operative or other invasive procedures, using a marking pen
- Time-Out Policy refers to a stopped period of time when all member of the procedure team participate in the positive identification of the patient, the intended procedure and the visualization of the marked site of the procedure. The present staffs present are to STOP what they are doing and participate in the Active Time out. Then, it can be that any staff not adhering to this policy will be subject to disciplinary action.
[M1]There is some useful information here but your Introduction needs to be more focused. What you have done is describe the time out policy; what you need to do is establish why the topic is important and why it needs to be investigated further. Yes, you do need to inform readers of what is entailed by using a time out policy but you also need to establish the importance of the topic to health care.
Give some context to your research problem – locate it in time and place. What is happening internationally, nationally in HK and in your hospital? Why is the topic important to you? Why is it important to health care and nursing? Why is it significant? You need to argue that your problem is important and convince readers that it is vital that the topic is investigated further. Use references to support your argument – the Introduction must be richly referenced. Use the Harvard referencing system.
[M2]The aim reflects broadly what you hope to achieve. The objectives should be specific goals which support the aim. Think about SMART objectives.
[M3]I suspect that you have too many questions to realistically answer in a BSc dissertation using a literature review as you methodology. Try to generate one or two clear, focused questions.
[M4]As with the Introduction there is a lot of useful information but it lacks a clear focus and it is a rather descriptive account of some aspects of the literature.
Your preliminary literature review (PLR) should:
I would expect a critical examination of the key concepts that are implicit in your research question.
I would also remind you that you need to use the Harvard referencing system in your final piece of work.
You need to ensure that the PLR is clearly focused on your research question and/or aims. Unfortunately your objectives are broad and there are rather too many research questions and this lack of focus is reflected in the PLR.
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