December 7, 2011 | Barb Carr

Root Cause Tip: Wrong Site Surgeries in Healthcare – Why are the Current TJC Protocols not Working?

Read a disturbing article from The Washington Post entitled, “The Pain of Wrong Site Surgery,” and it truly made me pause.

Seven years have passed since TJC provided a “universal protocol” outlining changes in pre-surgery routine. These included surgical site verification, and what was termed a “timeout” prior to any surgery. Based on data collected through self-reported events (not the most reliable data due to inconsistent reporting), and state provided information, there are still wrong site surgeries occurring at an estimated rate of 40 per week in the US. That is a staggering number, approximately 2,100 per year.

The article referenced Peter Pronovost, the Medical Director of the John Hopkins Center for Innovation in Quality Patient Care, stating that studies of wrong-site errors have consistently revealed a failure by physicians to participate in a timeout. This lack of participation is ritualized compliance or doctor’s lip service to the rules. That statement while true shows that even with the new protocols in place, there was little or no change in performance.

Comparing the TJC actions with the statements from Mr. Pronovost, it is clear to me that these actions are being implemented without an understanding of the Root Causes. These are all policy-based initiatives that in the end are dependent upon people following and adhering to policies and procedures.  This shows that if we do not analyze situations and find root causes, we will simply implement weak safeguards that do not fix the issue or change behavior.

From the TapRooT® perspective, let’s evaluate the “universal protocol” implemented in 2004:

1)   Verification of preoperative details – Quasi-Safeguard … admin control dependent on a human action.

2)   Marking of the surgical site – Quasi-Safeguard … admin control or “label” if you will, dependent on a human action.

3)   Timeout prior to procedure – Quasi-Safeguard … admin control or policy dependent on a human action.

All of these placed into current surgical systems and simply placed “over” the current processes have simply not worked.  You are now seeing, based on the statements from Mr. Pronovost and the alarming numbers of wrong site surgeries still occurring, that we have a “SPAC Not Used.”  This based on the current medical culture makes sense if people working in the process feel they are above the rules.

If TJC had performed a more thorough analysis of the actual causes, you might find that there are many other possible causes to these issues:

1)   Enforcement NI – if the attitude that “I am above this” or “I should not have to do this” has become an ACCEPTED practice amongst healthcare providers.  Thus, allowing the culture to grow without or with little consequence except to the patient.

2)   Accountability NI – if it is believed that others are responsible for detecting these errors or are responsible for ensuring proper performance.

And there are likely others. I am not stating that I have those answers. I have not gathered the data or analyzed it. But I can tell you that without a more thorough analysis these problems will continue to happen. Simply applying Quasi-safeguards as listed in the 2004 protocol, without any additional measures to identify or address the actual root causes means you are addressing the Causal Factor without actually knowing the causes. These weak fixes that read well, are not based on actual root causes and, as they are showing, are not having a lasting affect on performance.

When similar events continue to occur (average of 40 per week), and we continue to try the same things over and over again, isn’t that the definition of insanity? And should it not also point out that the corrective actions and measures taken have not worked, were not effective, and we need to revisit not only the fixes, but the analysis as well? Food for thought …

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