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Cincinnati Children’s Surgeon Creating Safest Operating Room

Tuesday, March 16, 2010

Health care is risky business. Even after implementing checklists, as Dr. Atul Gawande urges in his book The Checklist Manifesto, the overall mortality rate in pediatric cardiac surgery remains around 3 to 4 percent.

“Safety checks are a great start – we’ve been doing them in our operating room since 2002 – but something needs to be done to go to the next level,” says Pirooz Eghtesady, M.D., Ph.D., a pediatric cardiothoracic surgeon in the Heart Institute at Cincinnati Children’s Hospital Medical Center. “We need to do something to get from a rate of three or four in 100 to one in a thousand, or one in ten thousand, as we see in other industries.”

For Dr. Eghtesady, that “something” is an ambitious effort to create “the safest operating room.” He envisions an OR with a glass ceiling – literally. Above it, he sees a control room where the safety equivalent of an air traffic controller or a stage manager monitors the many intraoperative activities of the diverse individuals who work down below. Parents would be invited to watch their own child’s surgery, if they wish. At the end of the procedure, families receive a DVD of the operation.

“When you have an MRI of your knee, you can get a copy of the images. In many areas of Cincinnati Children’s, parents can participate in and watch what happens to and for their children,” says Dr. Eghtesady. “Why not in the OR? We need to be transparent, and families should know that a confident and committed team is taking care of their child – a team that believes safety is the number one priority.”

Making surgery safer

For each serious safety event at a hospital, there are many small and often unnoticed incidents that never materialize into problems. Eliminate most of these and the number of medical errors would decline dramatically. That’s the idea behind the Heart Institute’s transformational improvement work.

If checklists are the first generation of safety training, the pediatric cardiac surgery team at Cincinnati Children’s is already at the second generation stage, videotaping every surgery. They are looking not just for errors or near misses but for any unexpected events, no matter how small. And, they’re developing tools that can be used in any OR, anywhere in the world, to eliminate these events.

The cardiac OR team outlined its approach to patient safety and changes they have made in the cardiac surgery operating room at Cincinnati Children’s at 9:30 a.m. Tuesday, March 16, at the annual meeting of the American College of Cardiology in Atlanta.

“The traditional way of thinking is to look at events that are directly linked to patient safety,” says Dr. Eghtesady. “I think that’s short-sighted, because there is no way to predict in advance which events are critical and which aren’t. We want to eliminate all events, because any event can lead to an undesired outcome.

“We’re accounting for events that never would have been recognized or captured before. Unless you eliminate all of them, you’re not going to get to the place where you have 100 percent assurance of safety.”

The cardiac OR team compiled a list of these unexpected events over a two-year period. For example, they noticed variations in the time it took for blood products to arrive in the operating room. This was not a deviation from standard practice and would not normally be considered an issue. But the cardiothoracic team took notice and then investigated the blood order and delivery process. They discovered a convoluted system involving numerous staff members. Not only was it inefficient, but it could have led to a serious problem if, for example, the blood was never delivered.

In all, the cardiac OR team recorded nine categories of recurrent patterns of unexpected events. These are patient instability, physical injury to the patient, communication failure, change of plan, medication related, blood product related, equipment misuse or malfunction, access related (such as an IV or central lines) and a miscellaneous category.

They then began implementing system changes and process improvement measures to reduce events in particular categories. In the case of blood delivery, for example, the perfusionist who needs the blood in the OR now goes directly to the blood bank to get it before the procedure begins, eliminating three or four steps in the transport process along the way.

“We hope that by whittling away we can reduce events and thus eliminate near-misses entirely,” says Dr. Eghtesady.

Less than a third of surgical cases were associated with an unexpected event, and if there was an event, the vast majority was single, isolated ones. Nearly a third were due to equipment issues, making the potential for system and process changes real.

The cardiac OR team is about to enter the third generation of safety. Its goal is to have a dedicated OR safety officer and to record the entire OR environment – from the moment patients enter the operating room to the moment they leave. The fourth generation would be the one in which a “stage manager” monitors the entire process.

“When people decide they need surgery, the first question they ask is, ‘Who is my surgeon?’ says Dr. Eghtesady. “But when they get on a plane they don’t ask, ‘Who is my pilot?’ We need to develop systems that are just as reliable and safe. We owe it to our children.”