Current Available Evidence Pointing to the Existence of the Problem of Non-Adherence to Time-Outs Leading to Wrong-Site Surgeries
In an interventional study, Rothman et al. (2016) recognize the presence of the QI issue of wrong-site surgery in clinical practice. They concur that this is the type of surgical procedure that is done on the wrong site or the wrong patient. However, they also make a very important inclusion – that it could also be the wrong operation conducted on the right patient. Most importantly, they state that the actual incidence of this quality indicator is about 1 in 5,000 cases (Rothman et al., 2016). They created large in-room LCD displays that showed to all the time-out procedure and checklist.Analysis of the Existing Evidence for the Problem and Choice of Quality Improvement in the Operation Room.
Jeanette and Elizabeth (2016) also agree in their article that “time-outs” are meant to prevent harm to the patient and to protect the surgical team. They categorically state that when wrong surgery occurs, the impact to both the patient and the surgical team is devastating in terms of consequences. The patient is scarred both literally and psychologically for life while the reputation of the surgical team members is also dented. This observation by these authors is an indicator of and evidence that the practice problem chosen at St. Joseph Pain and Rehabilitation Center indeed exists.Analysis of the Existing Evidence for the Problem and Choice of Quality Improvement in the Operation Room.
The Agency for Healthcare Research and Quality (AHRQ) is a body that is known to guide and facilitate quality improvement in healthcare organizations. In its publication on the Patient Safety Network, it tackles this time-out problem by writing about the practice issue of wrong-procedure, wrong-site, and wrong-patient surgical operations (AHRQ, 2019). They state in this piece of evidence from literature for the presence of this problem that operations on the wrong site or patient are referred to as never events. This is because they are errors that are not supposed to happen as they invariably point to a major safety concern in the organization.Analysis of the Existing Evidence for the Problem and Choice of Quality Improvement in the Operation Room.
Mulloy and Hughes (n.d.) also provide evidence with literature in support of the presence of the chosen practice problem and its severity as a quality indicator. To begin with, they acknowledge the problem but state categorically that it is a preventable medical error that should not happen in the first place. They admit that wrong-site surgery (WSS) is a present and realistic threat to patient safety (Mulloy & Hughes, n.d.). Last but not least is evidence from Chung (2015). This author presents the evidence in support of the presence of this problem by showing statistics about sentinel events as collected by the JCAHO. For instance, between 2003 and 2014 or about 10 years there were a total of 8,275 sentinel events recorded by JCAHO. Of these, 5,563 were self reported while 2,712 were non-self reported (Chung, 2015). However, the fact that majority of these cases were self-reported indicates that these statistics might be an underestimation of the magnitude of the problem.Analysis of the Existing Evidence for the Problem and Choice of Quality Improvement in the Operation Room.
The Quality Improvement Process for Addressing the QI Issue
Quality improvement (QI) is the process of systematically correcting clinical problems in healthcare that negatively impact the quality of care delivered as well as patient safety. In this case, the QI process will include:
The QI model that will be used to actualize the QI project will be FADE. This is an acronym that stands for Focus, Analyze, Develop, and Execute (Spath, 2018). The QI tool that will be used in the QI plan will be the time-out checklist proposed and recommended by the JCAHO.Analysis of the Existing Evidence for the Problem and Choice of Quality Improvement in the Operation Room.
Conclusion
Quality improvement is a major undertaking in any serious healthcare organization. It is initiated by data from dashboard metrics that track quality benchmarks such as the rate of wrong-site operations per 1,000 patient procedures. At the St. J
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