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Don't let chart errors lead to further medical mistakes

Radiology Administrator's Compliance and Reimbursement Insider, June 1, 2008

Tragedies such as wrong-site surgeries can take a healthy kidney and leave a cancerous one: this happened recently at a St. Paul, MN, hospital. Such events can happen even if the facility follows The Joint Commission’s Universal Protocol™. So what can a radiology administrator do?

Radiologists and radiology departments can take steps to avoid these terrible errors, says Alice G. Gosfield, Esq., a healthcare attorney and consultant at Alice G. Gosfield & Associates, PC, in Philadelphia. If the radiology department errs, even the best efforts afterward to follow protocols may not prevent a disaster. Surgical teams should review diagnostic images (x-rays, CTs, MRIs) to confirm the surgical site before surgery.

Follow Joint Commission protocol

Every Joint Commission–accredited hospital has had to comply with surgical safety protocols, including the Universal Protocol, since 2004. The current protocol applies to every surgery and to any other invasive procedure with more than minimal risk.

Currently, the protocol calls for three steps:

1. Review documents. In the preoperative area where the patient is interviewed, the preop nurse uses a PDF to confirm that the patient is who they say they are, using the patient’s date of birth or medical record number. The operating room personnel must ensure that the anticipated procedure is consistently documented in various areas of the chart. The nurse should ask the patient to confirm his or her name, the procedure, and the site of the surgery. Several staff members, including a preop nurse and an anethesiologist, should repeat this confirmation.

2. Reconfirmation. Before entering the operating room, the doctor must meet with the patient, reconfirm the surgery and site, and then write his or her initials on the surgery site.

3. Timeout. Doctors must hold a timeout immediately before the procedure. At this point, the entire team steps back and reconfirms that this is the right patient, the right procedure, and the correct site.

For further clarifications, review The Joint Commission (formerly JCAHO) implementation expectations below.

Closing the loophole

But in the case of the St. Paul hospital, the Universal Protocol left a loophole: The chart was incorrect from the beginning. A mistake in the chart made several weeks earlier became accepted as accurate. Although the investigation is ongoing, it’s possible the original scan might have been mislabeled, says Gosfield. The radiology department may have marked the image incorrectly, making it appear that the cancerous growth occurred in one kidney when it actually occurred in the opposite organ, she says. In this situation, radiology departments must safeguard the process by labeling the image the right way.

There are several places in the labeling process where errors might occur. For example, if the radiologist saw the tumor in the right kidney but misspoke and indicated the left kidney, the transcriptionist would not know the difference.

The transcriptionist also could have simply made a typographical error and typed “left” instead of “right.” Perhaps one of the physicians taking care of the patient mistakenly documented the wrong kidney, which then was promulgated in the chart.

In any case, there was an error, and as a result, even the patient became misinformed, as he or she would likely have been queried several times as to which kidney was to be removed.

Make sure your radiology department strives for accuracy when labeling images.

Insider source

Alice G. Gosfield, Esq., Alice G. Gosfield & Associates, PC, 2309 Delancey Place, Philadelphia, PA 19103, 215/735-2384; agosfield@gosfield.com.

Review standards to prevent wrong-site surgery

The following is a review of the implementation expectations for preventing wrong-site, wrong-procedure, and wrong-person surgery. These guidelines provide detailed implementation requirements, exemptions, and adaptations for special situations, and are reprinted from the Joint Commission (formerly JCAHO) Web site.

Preoperative verification process

Verification of the correct person, procedure, and site should occur (as applicable) at the following times:

• When the surgery/procedure is scheduled
• At admission or entry into the facility
• When the responsibility for care of the patient is transferred to another caregiver
• When the patient is involved, awake, and aware
• Before the patient leaves the preoperative area or enters the procedure/surgical room
• Prior to the start of the procedure, ensure availability and review of the following:
• Relevant documentation (e.g., H&P, consent)
• Relevant images, properly labeled and displayed
• Any required implants and special equipment

Marking the operative site

Once the patient and procedure are confirmed, use the following steps to indicate the correct site for the surgery:

Make the mark at or near the incision site. Do not mark any nonoperative site(s) unless necessary.

The mark must be unambiguous (e.g., use initials or “yes” or a line representing the proposed incision; consider that “X” may be ambiguous).

The mark must be visible after the patient is prepped and draped.

The mark must be made using a marker that is sufficiently permanent to remain visible after completion of the skin prep. Adhesive site markers should not be used as the sole means of marking the site.

The method of marking should be consistent through-out the organization.

At a minimum, mark all cases involving laterality, multiple structures (e.g., fingers, toes, lesions), or multiple levels (e.g., spine). Note: In addition to preoperative skin marking of the general spinal region, special intraoperative radiographic techniques are used for marking the exact vertebral level.

The person performing the procedure should mark the site.

If possible, marking must take place with the patient involved, awake, and aware.

Final verification of the site mark must take place during the timeout.

A defined procedure must be in place for patients who refuse site marking.

In some situations, you don’t need to mark the site as listed above. Such situations include the following:

Single organ cases (e.g., cesarean section, cardiac surgery)

Interventional cases for which the catheter/instrument insertion site is not predetermined (e.g., cardiac catheterization)

Teeth—indicate operative tooth name(s) on documentation or mark the operative tooth (teeth) on the dental radiographs or dental diagram

Premature infants, for whom the mark may cause a permanent tattoo

Timeout immediately before the procedure

The timeout must be conducted in the location where the procedure will be done, just before starting the procedure. It must involve the entire operative team, use active communication, be briefly documented—such as in a checklist (the organization should determine the type and amount of documentation)—and must, at the least, include:

• Correct patient identity
• Correct side and site of procedure
• Agreement on the procedure to be done
• Correct patient position
• Availability of correct implants and any special equipment or requirements

The organization should have processes in place for reconciling differences in staff responses during the timeout.

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