Patient Safety in Neurosurgery.ppt

patient safety in neurosurgery interactive moc program aans/abns 2011 module 1 part 1 torres f 3098890 torres f 3098890 torres f 3098890 torres f 3098890 torres f 3098890 torres f 3098890 overview the following moc exercise is composed of two sections: 1) an animated patient care scenario in which dr. anderson, a junior neurosurgeon, performs an operation at the request of a colleague, dr. montpierre, and encounters an error. 2) a followup, interactive module focusing on patient safety aspects of the case and an analysis of the error. introduction the scenario begins with a conversation between dr. anderson and dr. montpierre during neurosurgical grand rounds dr. montpierres pt torres wants to meet you before surgery torres frank 3098890 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 and three patients waiting for you in clinic or mens 7 6 5 4 3 2 1 montagemusic started 0.8 another “guerney” ambient noise on bracelet 11 li l cea 11 li r vps 12 montpierre r brain biopsy 12 montpierre r brain biopsy 13 chao l4-5 tlif 13 chao c3-7 lami 14 patil l crani 14 patil r crani 15 montpierre r brain biopsy main operating room authorized personnel only or 10-11 or 12-15 stall time dr. montpierres pt torres wants to meet you before surgery stall time l cea r vps r brain r brain l4-5 tlif c3-7 lami l crani 15 montpierre r brain biopsy 11 li l cea 11 li r vps 12 montpierre r brain biopsy 12 montpierre r brain biopsy 13 chao l4-5 tlif 13 chao c3-7 lami 14 patil l crani 14 patil r crani 15 montpierre r brain biopsy torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 3098890 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres f 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres f 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres l 3098890 torres l 12/24/72 torres l 12/24/72 torres l 12/24/72 torres f 12/24/72 m 11 li l cea 11 li r vps 12 montpierre r brain biopsy 12 montpierre r brain biopsy 13 chao l4-5 tlif 13 chao c3-7 lami 14 patil l crani 14 patil r crani 15 montpierre r brain biopsy great lets get started torres, lou 3098890 38m 12/24/72 torres, lou 3098890 38m 12/24/72 torres, lou 3098890 38m 12/24/72 oh no! what have i done? dr. anderson has discovered that an error has occurred. help him locate the information which produced it and identify the mistake. by clicking “continue” below, you will enter an “explore” screen, and have a chance to review scenes from the scenario and search for information which can be used to identify the error which occurred and its cause. you will have unlimited time to review the information in the selected scene frames but cannot exit the “explore” page for a least 1 minute. once you have arrived at a hypothesis regarding the nature of the error click the green “exit” bar. you will then have a chance to choose from among a set of potential errors the one that best matches your analysis of the scenario. if you choose incorrectly, you have the option of replaying the animated scenario from the beginning or studying the “explore” page again. interactive component instructions continue replay movie time elapsed block click an image below to explore. the two patients are both biopsies. you ought to be able to get them done quickly, no? yeah, easy for you to say. ive got a full days worth of clinic patients waiting. wouldve helped if youd given me a little more info. go back go back go back go back go back exit: click here when youve found out what went wrong. replay movie go back what went wrong? click your answer. the navigation software must be broken! the pathology lab mixed up the sample. im operating on the wrong side! the biopsy needle isnt working right. the lesion must have regressed. im operating on the wrong patient! im doing the wrong procedure! i have no idea. need to explore more. go back what went wrong? click your answer. the navigation software must be broken! the pathology lab mixed up the sample. im operating on the wrong side! the biopsy needle isnt working right. the lesion must have regressed. im doing the wrong procedure! not this time. theres a better explanation. take a little time to explore some more. i have no idea. need to explore more. go back im operating on the wrong patient! time elapsed block click an image below to explore. the two patients are both biopsies. you ought to be able to get them done quickly, no? yeah, easy for you to say. ive got a full days worth of clinic patients waiting. wouldve helped if youd given me a little more info. go back go back go back go back go back exit: click here when youve found out what went wrong. replay movie go back what went wrong? click your answer. the navigation software must be broken! the pathology lab mixed up the sample. im operating on the wrong side! the biopsy needle isnt working right. the lesion must have regressed. im operating on the wrong patient! im doing the wrong procedure! i have no idea. need to explore more. go back what went wrong? click your answer. im operating on the wrong patient! correct! wrong patient surgery dr. anderson operated on the wrong patient (the wrong torres). the mistake was the result of overlooking a mismatch between radiographic materials and identifiers traveling with the patient. in this scenario, dr. anderson reviews radiographs that belong to a different patient with the same last name. the surgeon could have avoided this problem had he been more careful about matching all pieces of patient specific information. continue wrong patient surgery several clues to the identity mismatch were presented, including: the name and number on the patients id bracelet differ from those on the navigation image birthdate on the consent form differs from that on both the print film and navigation image different gender data on the consent and navigation annotation continue wrong patient surgery although it would have been helpful if dr. andersons colleague had alerted him to the presence of two patients sharing the same last name, the attending surgeon is still responsible for the complete review of all patient-specific pieces of information. as this case shows, a single crucial mismatch of information one not always visualized during routine timeout procedures can produce an error in treatment. the only safeguard against this sort of error is diligence on the part of the resp