Negligence of the medical personnel is among the best-known causes of breach of safety culture. It ranges from the minor violations of the rules to the severe mistakes that sometimes bear irreversible consequence, known as “never events.” Several ways of overcoming the issue have been suggested, most often the educational programs aimed at increasing the understanding of the safety culture and responsibility. The procedures incorporated in the medical process for ensuring safety, such as the time-out prior to the surgery, have also suffered from negligence, sometimes resulting in performing of invasive procedure on the wrong body part or a wrong patient.
The time out is performed on a patient that is subject to a surgical procedure. The aim of the time-out is the confirmation of the patient, procedure, and surgical site. The latest amendments also demand the verification of the required documents, diagnostic data, the presence of all the necessary instruments and implants, the information on the appropriate medications, and even the positioning of the patient.
While the appropriately executed time-out effectively eliminates all the possible mistakes, the statistics continue to show the ongoing tendency of the wrongly performed operations, with the survey suggesting that up to 50% of spine surgeons admitting at least one such flawed operation (Mody, Nourbakhsh, Stahl, Gibbs, Alfawareh, & Garges, 2008) and all of 36 hospitals providing neurosurgery admitting at least one case of wrong-site operations (Shinde & Carter, 2009). Interestingly, in the latter case, the hospitals which undertook more rigorous time out procedure reported better results, but none of them was flawless.
There are two primary reasons for this, and both lie within the safety culture domain. The first is aimed at the time out itself. The time out should be performed with the active participation of all the available personnel and, ideally, the patient. Besides, the procedure must be standardized in all the institutions. The second approach needs to tackle the fact of negligence exhibited by the personnel. While the correct performance of the time out does not guarantee the absence of the “never event” such as the surgery of the wrong patient, the overwhelming majority of the occurrences take place when it is either ignored or performed incorrectly.
Thus, the establishments with low safety culture are prone to negligence. Thus, it is advised to implement the Plan-Do-Check-Act (PDCA) quality improvement model. Additionally, the importance of timely benchmarking the level of safety culture is recommended. Currently, the Agency for Healthcare Research and Quality (AHRQ) provides a number of safety culture surveys that allow for comprehensive measurement of the safety culture of any given department, including surgical units.
Finally, the introduction of the just culture concept instead of the “no blame” approach still present in some establishments will presumably reduce the never events, as the just culture targets the type of behavior instead of the consequences of action (Dekker, 2012). For instance, failing to perform the time out does not always results in adverse effects for the patient, but should nevertheless be treated as a malpractice.
The suggested directions for quality improvement comprise the emphasis on teamwork and defined processes, which aligns with Total Quality Management (TQM) model, and its more recent counterpart, the Continuous Quality Improvement (CQI) strategy (Riley, Liang, Rutherford, & Hamman, 2008). Besides, the clinical activities oriented at understanding and promoting safety culture are recommended, such as designing a safety checklist, working in groups to detect the negligent and reckless behavior, and designing an approach to reduce the possibility of human error and at-risk behavior.
The negligence in surgical procedure still takes place today. The correct quality improvement models and strategies, as well as the learning activities aimed at increasing safety culture, are absolutely required to eliminate the factor of reckless behavior and minimize human error.
References
Dekker, S. (2012). Just culture: balancing safety and accountability. Burlington, VT: Ashgate Publishing.
Mody, M. G., Nourbakhsh, A., Stahl, D. L., Gibbs, M., Alfawareh, M., & Garges, K. J. (2008). The prevalence of wrong level surgery among spine surgeons. Spine, 33(2), 194.
Riley, W., Liang, B., Rutherford, W., & Hamman, W. (2008). Structure and features of a care enhancement model implementing the patient safety and quality improvement act. Web.
Shinde, S., & Carter, J. A. (2009). Wrong site neurosurgery–still a problem. Anaesthesia, 64(1), 1-2.