Development of a culture of patient safety and good communication is also critical. Learning and practicing the procedures in a simulation environment was encouraged. Checklists, site marking, and ultrasound localization are also useful. Recommended strategies included formal standardization of Universal Protocol and timeouts for invasive procedures anywhere, not just in the OR. If the PACS system is down, you may not have immediate access to the images at the bedside. That’s particularly problematic in today’s computerized environment. Images were often not available at the time of the procedure. ![]() The authors found 30 root causes in the 14 cases, most often including communication issues, failure to follow policy or procedures, and equipment issues. Medical image verification was not done in 7 of the 10 cases where information was available. Laterality was missing from the consent form in 10 and the site was not marked in 12. The most frequent associated factor was failure to perform a timeout (12 of the 14 cases). An attending was present in 6 cases and a nurse was present in just three. ![]() A resident performed the procedure in 10 cases and an attending performed two. Some factors identified from 14 wrong-side thoracenteses likely also contribute to wrong-side chest tube insertions2. Failure to perform the sort of timeout and verification process that we use in the OR is a major reason for wrong-side chest tube insertions. ![]() In the early 1990’s, wrong-side chest tube insertion was one of the leading “wrong site” procedures in our New York Patient Occurrence Reporting and Tracking System (NYPORTS). But they omitted a key essential step – ensuring the chest tube will be inserted on the correct side.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |