Responding to Medical Error

Yesterday, Paul Levy posted an entry on his blog about a recent surgical error at BIDMC.

IS and the clinical departments of BIDMC have a very strong collaborative relationship. Working together, we first enhance processes, then automate them, since even the best technology is generally not the solution to workflow and communications problems.

Here's the application enhancement we're making as part of a process change in the Operating Room to prevent future patient harm.

Standard Operating Process in the OR includes a "time out" by all OR personnel in the moments before surgery to double check all aspects of safety - equipment, right surgical site, team readiness etc. Currently the "time out" is documented on the paper intra-operative record, which means that the scrub nurse needs to look at both the paper record and the electronic peri-operative information system during the "time out." We will add a "Time Out" button to the electronic OR journal screen containing the case times. When this button is clicked we will pop up a window with the "time out" fields. The nurse will fill in the time out information and enter her/his password. We will not allow the nurse to enter an incision time for the case unless the "time out" has been completed, with one exception - we will provide a check box on the time out screen to indicate the time out could not be completed prior to incision due to a life-threatening situation.

The standard process we've put in place to respond to sentinel events such as this one is that the root cause is reviewed with the Board (PCAC committee) and the Quality Improvement Directors. IS staff work with Quality Improvement Directors to determine which process improvements need to be made, then what additional automation should be added. Using this approach, we've created a balanced way to add new technology at the appropriate time.