In recent years, establishing no-blame culture has become a popular practice in surgical healthcare. It means that if a sentinel event occurs - such as a wrong-site surgery, a nosocomial infection or a medication error - the facility should look at the event as a systematic failure rather than as the fault of one or several individuals.
Continually reviewing, streamlining and improving your center's clinical processes is the backbone of any good QI program. However, the problem with a true no-blame culture is that it removes the notion of personal and collective accountability for first doing no harm to the patient. Effective clinical protocols don't exist in a vacuum. Practitioners must follow the protocols uniformly and institutions must enforce them without exception.
Nowhere is this goal more important than when it comes to abiding by the new universal protocol designed by JCAHO to eliminate potential for a wrong-site, wrong-patient or wrong-procedure surgery. The protocol's final step - the pre-operative timeout to confirm the patient, surgical site and procedure - is the most tempting and the most dangerous to omit.
With the surgeon scrubbed in, the patient anesthetized and the surgical site marked, some practitioners just want to get moving. After all, the odds of a wrong site/patient/procedure surgery are very low in general. The OR schedule is packed. And we've already taken the safety precautions. Besides, the administration begrudges every extra minute spent in the OR. What's the harm in starting - and ending - the case a little sooner?
We must combat exactly this type of thinking. Here at Kaiser Foundation Hospital in San Francisco, we've set the bar very high and established a zero-tolerance policy when it comes to violations of the universal protocol.
If an OR team fails to take a pre-op timeout to confirm the correct patient, surgical site and procedure, the surgeon, anesthesia provider and circulating nurse have their OR privileges suspended - even if the procedure in question otherwise went off without a hitch. No exceptions, no excuses.
At our hospital, the anesthesia provider has the first responsibility to initiate the timeout. If the anesthesia provider fails to do so, the task falls to the circulating nurse, then to the surgeon. If no one takes the initiative, we'll censure all three team members.
I'm pleased to say we've never had to enforce the policy. Moreover, buy-in has been no problem whatsoever. Our nurses, surgeons and anesthesia providers all give the policy their full support.
Wrong-site-surgery prevention is a way to move past the no-blame culture to a just culture in which every OR meets the same standards of care, and practitioners and administration do our parts to ensure the safety of our patients.