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  • Surgical Safety at Rhode Island Hospital

  • In the wake of the surgical errors in 2007, Rhode Island Hospital has taken a number of steps toward its goal to provide the safest surgical care in the country. The hospital has taken a systematic approach to problem solving that fosters an atmosphere of transparency so that people will report errors, near misses and any unsafe conditions.

    The leadership at Rhode Island Hospital has established a dynamic structure to improve quality and patient safety.  This structure involves nurses, physicians and staff at all levels, from the front line up to the Board of Trustees. The hospital has done this in several ways:

    Working with national quality organizations

    In July 2009, Rhode Island Hospital partnered with the Center for Transforming Healthcare to improve the safeguards to prevent patients from wrong site, wrong side and wrong patient surgical procedures. The project team, which consisted of hospital leadership, surgeons, operating room directors and staff, were trained in Robust Process Improvement (RPI) methods by experts from the Center. RPI is a fact-based, systematic, and data-driven problem-solving methodology. It incorporates specific tools and methods from Lean Six Sigma and change management methodologies. Using RPI, the project teams discovered specific risk points and contributing factors and implemented interventions and controls to foster the elimination of wrong site, wrong side, and wrong patient surgical procedures.

    Building on some of the successes gained from the use of RPI in surgical services, several months ago Rhode Island Hospital began collaborating with experts from Covidien-a health care company with expertise in Lean Six Sigma-to help Rhode Island Hospital expand the use of tools from Lean Six Sigma across our hospital. This project, called Operational Excellence (OpX), aims to improve our work environment and engage our employees in identifying and acting upon improvement opportunities with the ultimate goal of improving the overall quality, reliability, safety and efficiency of the care we deliver.

    In January 2010, Rhode Island Hospital joined University Health Systems Consortium (UHC), an alliance representing 90% of the nation's non-profit academic medical centers, enabling the hospital to benchmark its performance and share best practices with similar large academic medical centers.

    In September 2010, ten physician leaders participated in the Patient Safety Executive Development Program offered by the Institute for Healthcare Improvement, an independent not-for-profit organization helping to lead the improvement of health care throughout the world. This intensive, seven-day program is designed to prepare those responsible for safety to be leaders of strong, effective patient safety programs. 

    More about our work with national quality organizations

    New standardized reporting system

    The hospital has emphasized a shared obligation to report safety issues.  Working with the state, Rhode Island Hospital took the lead in rolling out a medical events reporting system (MERS) in July 2010. The system has since been adopted by all Rhode Island hospitals.   Anyone who works in a hospital can report an event, a near miss, or an unsafe condition.  They can use their name or submit a report anonymously.

    Almost all the reports submitted by Rhode Island Hospital staff have a name attached, and they involve both surgical and non-surgical matters.  There is a protocol for responding to reports.  They are first reviewed by the manager of a particular area, who is alerted electronically about the problem through the system.  The report then is reviewed by a quality professional who might also consult with risk management before deciding what steps to take.

    Non-surgical examples of how the system has worked have included a report that the cherry flavored drink given to patients about to undergo a colonoscopy was making it difficult to view the colon. As a result of the report, the hospital's pharmacy immediately stopped using the drink.  In another case, someone noticed that the automatic doors in the hospital were closing too fast when people in wheelchairs were coming through.  The doors now close more slowly.

    The surgical areas have also prompted reports to the system, many of them concerning near misses.  This has allowed the hospital to better assess whether certain surgeries or practices (or certain individuals) are prone to problems, or whether other issues might lead to surgical errors.

    The reporting system has helped in this effort.  Put another way, in the past a near miss might never have been reported, leaving the hospital with no clear vision of the issues that could lead to surgical errors. The old reporting systems did not have the ability to route reports about near misses or unsafe conditions automatically to managers and other hospital executives and lacked a comprehensive follow-up component.  The MERS system is designed to deal with these issues by automatically sending e-mail alerts to managers and others so that reports get proper attention.

    Now the hospital is getting the information it needs to analyze issues, spot patterns and take corrective actions.

    The hospital has become much more sophisticated about using quality improvement and prevention tools; for example, one component in the reduction of wrong-side surgery is to improve the way surgeries are "booked," so that surgical teams have accurate, up-to-date information about a patient and the procedure he or she needs.  The more accurately you can book surgery, the better your chances of preventing surgical error.

    More about error reporting and patient safety

    Just culture

    Along with working to create a reporting-training-safety regimen, the hospital has also moved to implement what is termed a "just culture," based on principles developed by David Marx.

    The notion is that there are three levels of responsibility for medical errors.  One is where someone makes a mistake that causes an adverse event; the second are situations where someone goes outside regular policies in an effort to improve a patient's quality of care but the effort results in an error; and the third involves a reckless or intentional disregard for policy that leads to an adverse event.

    By using this three-level system, a hospital can better evaluate issues and take the right corrective actions, including fixing ineffective systems.  There is also an understanding in this system that, except in cases where someone has intentionally caused an adverse event, the hospital will help doctors, nurses and staff involved in medical errors so that they do not repeat the mistakes.

    More about how we are creating a just culture at Rhode Island Hospital

    Extensive review of operating rooms

    After the three neurosurgery errors in 2007, the hospital undertook a head-to-toe review of the service.  New leadership was appointed, a new neurosurgery ICU staffing model was created, and construction is underway to move the neurosurgery offices from a separate building, in which they had been located, into the hospital.

    As part of a Rhode Island Department of Health Consent Decree, the hospital closed all operating rooms for the day on November 21, 2009 to take the staff through didactic and experiential learning of a standardized protocol, which has resulted in a significant decrease in the variation from the pre-op script. As part of the consent decree, cameras were installed in operating rooms last spring so monitors could conduct random checks of compliance with the universal protocols required before a surgeon begins an operation.  The hospital has been working to ensure all members of the surgical teams "own" this so-called timeout period that occurs prior to the first incision.

    More about safety in our operating rooms

    Use of IT systems to help prevent errors

    Rhode Island Hospital is one of a few hospitals using health IT systems to help ensure patient safety, including tech-based checkpoints in operating rooms.  Hospital staff use the latest advances in technological systems to monitor patients' health and to help ensure that they receive the safest quality care.

    The systems that have been adopted, which include the "closed loop" system of medication and other electronic patient records, help to keep patients safe by providing accurate recorded histories and avoiding potential errors that might occur if our doctors and staff relied instead on human memory. This recorded information of patients' conditions, medication usage, and other vital health factors can be viewed and discussed by patients and their health care team. Further safeguards are in place, such as checklists, multiple sign-offs and reviews, and these safeguards also help prevent errors. Patients play a key role in helping the hospital's health care teams succeed. The hospital encourages patients to note any changes in their health and to share this information so it can be recorded by their health care teams.

    More about how our technology impacts patient safety