Communication is Key to Patient Safety

If being carded and stamped is annoying before entering a night club, why would patients embrace the idea before entering an operating room?

The answer is simple: It could save their lives.

Hospitals are increasingly using surgical verification protocol to ensure the right patient gets the right surgery on the right operative site. Surgical site verification works, according to a recent survey conducted by OHA Insurance Solutions, Inc. (OHAIS), a medical liability insurance company created by the Ohio Hospital Association. Of the 23 hospitals surveyed, 22 have adopted some form of standardized surgical procedure verification protocol, which has prevented a wrong patient, wrong site or wrong procedure occurrence in at least 13 instances identified by the facilities. Thanks to the protocol, no adverse events were reported.

Hospitals can adopt a national protocol from the Joint Commission, a hospital accrediting organization; the Ohio Patient Safety Institute’s (OPSI) Ohio Surgical/Procedural Verification Protocol – the nationally renowned and first state-specific protocol in the country – or a combination of protocols. Both protocols require surgical teams to verify the patient is the correct patient before the surgery, use a marker to literally mark the operative site and conduct a “time out” preceding the procedure to engage communication among the surgical team.

The OHAIS survey also reviewed hospital protocols to eliminate dangerous medication abbreviations – which can lead to another type of medical error that can be prevented with improved communication. While doctors’ illegible handwriting is often a cliché joke at dinner parties it could mean the difference between a life-saving dose and potentially deadly overdose of certain medications.

Twenty-two of the 23 hospitals surveyed by OHAIS have adopted a standardized “do not use” list of abbreviations. Since implementing policies banning dangerous medical abbreviations, 11 of the surveyed hospitals noted a decrease or elimination of medication errors related to abbreviations. Expanding safety precautions even further, 12 hospitals added additional abbreviations to their internal “do not use” lists.

Helping hospitals learn the value of communication in protecting patient safety is the subject of a Columbus conference on March 16, “City Wide Patient Safety Conference: Enhancing Communication Among Caregivers and Patients.” Sponsored by Grant Medical Center, The Ohio State University Medical Center, Mount Carmel Health System, OhioHealth and Columbus Children’s Hospital, the conference dissects how communication failures are the root cause of unanticipated adverse events, including death in the worst-case scenario.

In the past, hospitals and caregivers were reluctant to talk about surgical or medication errors because of the fear of liability or corrective action. That trend is shifting.

“Health care is evolving. Hospitals are encouraged to promote a culture of learning, rather than a culture of punishment” said Rosalie Weakland, OHA director of quality improvement and liaison with OPSI. “The health care community is embracing the idea that communication is the key to patient safety.”

OHA Insurance Solutions, Inc. surveyed 23 hospitals to evaluate their compliance with national and the Ohio Patient Safety Institute patient safety goals regarding the use of surgical site verification protocols and dangerous abbreviations protocols. The survey, in which participants responded to questionnaires, was conducted between January and October of 2006. OHAIS also conducted in-person interviews with staff from each hospital following completion of the written survey. Of the participating hospitals, 17 are insured with OHAIS and six are insured with other insurance companies.

Media representatives are invited to attend the March 16 City Wide Patient Safety Conference. Please RSVP to Tiffany Himmelreich at 614.221.7614 or tiffanyh@ohanet.org.

OHA Insurance Solutions, Inc. (OHAIS) was created by the Ohio Hospital Association (OHA) in 2003 to help bring long-term availability, predictability and stability to the Ohio medical professional liability marketplace for hospitals and physicians. OHAIS, a hospital-owned company, strives to ensure all Ohioans have access to health care by enabling Ohio’s physicians and hospitals access to medical malpractice insurance. Visit OHAIS’ Web site at www.ohainsurance.com/.

The Ohio Patient Safety Institute is a subsidiary of the Ohio Health Council, founded by the Ohio Hospital Association, the Ohio State Medical Association, and the Ohio Osteopathic Association. Through this collaboration and common effort, OPSI has the ability to work with over 170 hospitals and 9,000 physicians in Ohio to improve patient safety for all Ohioans. Visit OPSI’s Web site at www.ohiopatientsafety.org/.

The Ohio Hospital Association was established in 1915 and currently represents 170 hospitals and 40 health systems throughout Ohio. OHA is a membership-driven organization that provides proactive leadership to create an environment in which Ohio hospitals are successful in serving their communities. Visit OHA’s Web site at www.ohanet.org. For information on top health care issues, visit the online OHA News Media Center at www.ohanet.org/media/.       

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