Pre-surgery 'time outs'

Efforts to avoid wrong-patient and wrong-site errors are not new, according to Marc Bennett, president and CEO of HealthInsight. Every facility in Utah has ongoing patient safety efforts. But to make things consistent and more effective, special trainings are going on now with more planned to look at the human error factors in medical mistakes and how to avoid them. Increasingly, he said, the efforts are becoming open to public scrutiny.

In some ways, at various hospitals, little will change, said Anne Brillinger, spokeswoman for University Hospital. "We have for several years now been doing in-service trainings for all OR personnel. They basically elucidate the same principles that will be in the JCAHO guidelines. Now we're working to formalize those policies.

"Time out is good for everyone. . . . When all those people are talking about the patient they are about to perform surgery on, it's a very good thing," she said, adding that she recently had surgery and was asked to mark which toe was being fixed. "I thought that was a heck of a good thing. As a patient you're going to protect your body parts. I'm pleased with this."

The Utah Department of Health has been proactive, working with a multi-agency effort to improve patient safety. In 2001, the department started collecting data on medical errors it determined must be reported. From Oct. 15, 2001, to Oct. 14, 2003, the sentinel system identified 76 "events" in Utah. Of those, 11 were wrong-site or wrong-patient surgeries, said Dr. Scott Williams, department executive director. It's a topic of personal importance, he added, because in his own family there was a serious medical error.

Both the national "To Err" report and health department officials make it clear that errors are "an expected result of humans working in a complex system," he said. It's unlikely there will ever be a foolproof system. "But we are interested in creating a system that prevents those expected errors from penetrating through to the patient."

Unfortunately, the old system of lawsuits and regulations provided more incentive to hide errors than fix them, he said. But the airline industry showed that the best way to fix errors is to create incentives for bringing them forward so they can be analyzed and dealt with, not repeated.

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