- Email: [email protected]
Characteristics and costs of surgical scheduling errors
The American Journal of Surgery (2012) 204, 468 – 473
Clinical Science
Characteristics and costs of surgical scheduling errors Rebecca L. Wu, B.S.a,*, Arthur H. Aufses Jr., M.D.a,b a
Department of Surgery, Mount Sinai Medical Center, 1 Gustave L. Levy Place, New York, NY 10029, USA; bDepartment of Health Evidence and Policy, Mount Sinai Medical Center, New York, NY, USA KEYWORDS: Scheduling errors; Booking errors; Wrong-site surgery; Safety
Abstract BACKGROUND: Errors that increase the risk of wrong-side/-site procedures not only occur the day of surgery but also are often introduced much earlier during the scheduling process. The frequency of these booking errors and their effects are unclear. METHODS: All surgical scheduling errors reported in the institution’s medical event reporting system from January 1, 2011, to July 31, 2011, were analyzed. Focus groups with operating room nurses were held to discuss delays caused by scheduling errors. RESULTS: Of 17,606 surgeries, there were 151 (.86%) booking errors. The most common errors were wrong side (55, 36%), incomplete (38, 25%), and wrong approach (25, 17%). Focus group participants said incomplete and wrong-approach bookings resulted in the longest delays, averaging 20 minutes and costing at least $320. CONCLUSIONS: Although infrequent, scheduling errors disrupt operating room team dynamics, causing delays and bearing substantial costs. Further research is necessary to develop tools for more accurate scheduling. © 2012 Elsevier Inc. All rights reserved.
Wrong-site surgery, including the wrong side, the wrong patient, and the wrong procedure, continues to occur at an alarming rate. It was the most frequently reported sentinel event in 2009 and the third most reported sentinel event in 2010.1 Although the exact incidence and prevalence of wrong-site surgery remain unknown, the Joint Commission estimated a national incidence rate as high as 40 per week.2 The Joint Commission Center for Transforming Healthcare also launched a wrong-site surgery project in 2009 and recently reported that the scheduling process is “ripe for errors.”3 Miscommunication between the surgeon, the individual scheduling the surgery (eg, a secretary or office manager), and the hospital’s scheduling office can easily result in incorrect or Supported by the Mount Sinai School of Medicine’s Summer Research Scholars Program. Rebecca L. Wu is a second year medical student. * Corresponding author. Tel.: ⫹1-718-662-8011; fax: ⫹1-212-4232998. E-mail address: [email protected] Manuscript received October 3, 2011; revised manuscript December 20, 2011
0002-9610/$ - see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2012.01.011
incomplete bookings. The Joint Commission’s project found that in 39% of cases errors that increased the risk of wrong-site surgery were introduced during the scheduling process.3 A few institutions have already implemented changes to their booking process. The Mayo Clinic studied surgical case listing accuracy at their medical center in 2008 and introduced changes to their surgery computer entry system.4 The Minnesota Alliance for Patient Safety initiated a surgery scheduling and verification project in 2009.5 Although these efforts begin to address the problems that can occur during the scheduling process, booking errors and the extent of their effects are still not well understood. This study analyzes the characteristics of booking errors and their impact on operating room staff and costs. Based on our findings, we also discuss potential solutions.
Methods Mount Sinai Hospital (MSH) is a tertiary care academic hospital with 49 operating rooms. We analyzed data from the
R.L. Wu and A.H. Aufses Jr. Table 1
Surgical scheduling errors
469
Laterality/site scheduling errors under a paper versus electronic reporting system*
Number of scheduling errors reported (related to laterality or site) Number of scheduled surgeries performed Error rate (%)
Paper reporting system
Electronic reporting system (MERS)
January 1, 2009–July 31, 2009 41
January 1, 2011–July 31, 2011 66
17, 053 .24
17, 606 .37
P value
.024
*The electronic reporting system, MERS, was implemented in the ORs in March 2010.
MSH electronic medical event reporting system (MERS) from January 1, 2011, to July 31, 2011. This database was implemented in the operating rooms (ORs) in March 2010. Nurses, physicians, and other staff members can submit reports anonymously or with identification. Information collected included the date and time an error occurred, a description of the error, and the location where the error was discovered or reported. To calculate an error rate, we obtained the total number of scheduled surgeries performed from MSH Perioperative Services. We also compared this error rate with the booking error rate under a paper-based medical event reporting system at MSH from January 1, 2009, to July 31, 2009. All the paper reports had to be signed by the individual submitting them. The paper-based reporting system only had records of booking errors related to laterality or site, so only the corresponding cases in 2011 (wrong side/site or missing side/site) were used for this comparison. To study the effects of scheduling errors, we held 3 focus groups with OR nurses and technicians. The focus groups consisted of OR nurses and technicians from the general surgery cluster (8 participants), orthopedics cluster (13 participants), and ophthalmology cluster (5 participants). During the focus groups, participants were asked questions such as (1) “What types of booking errors have you encountered?” (2) “How often do you encounter these types of booking errors?” (3) “What effects do booking errors have?” and (4) “How long does it take for these booking errors to be corrected?” The average delay because of booking errors was estimated based on the numbers cited during these focus groups. OR cost data were also provided by MSH Perioperative Services. To estimate the OR room costs per minute, we divided the general OR costs per hour, $968, by 60 to get $16 per minute. The OR costs include the salaries of OR nurses, technicians, and support staff; the costs of disposable supplies; and the costs of minor equipment (excludes the costs of capital equipment). The surgeon’s and anesthesiologist’s fees were not included. This per-minute calculation was used to estimate the average costs of scheduling errors. MSH’s Institutional Review Board determined that this study did not meet the definition of human subjects research and therefore did not require their review or approval.
Results There was a significant increase in the reporting of laterality or site scheduling errors from the paper-based re-
porting system in 2009 to the electronic reporting system (MERS) in 2011. The error rate from January 1, 2009, to July 31, 2009, was .24% (41) compared with an error rate of .37% (55) from January 1, 2011, to July 31, 2011 (P ⬍ .05) (Table 1). Although MERS reports can be submitted anonymously (unlike the paper reports), all the booking errors were submitted with identification. From January 1, 2011, to July 31, 2011, there were 151 booking errors (.86%) reported out of 17,606 scheduled surgeries. No wrong-site surgeries occurred. The most common type of error was wrong-side booking (55, 36%) followed by incomplete booking (38, 25%), wrong approach (25, 17%), wrong procedure (14, 9%), wrong site (7, 5%), wrong patient information (7, 5%), missing side (3, 2%), wrong procedure and wrong side (1, 1%), and wrong patient (1, 1%) (Fig. 1). Incomplete bookings consisted of cases in which additional procedures (eg, diagnostic laparoscopy, cystoscopy, or ureteral stent placement) were added or bilateral cases were scheduled only on 1 side. Missing-side bookings consisted of cases that did not indicate any side. Wrong-approach bookings involved a change in approach (eg, from laparoscopic to open or open to laparoscopic) before making any incisions. Bookings with the wrong patient information had the wrong date of birth, the wrong medical record number, or a misspelled name. There was 1 wrong patient booking in which the wrong patient (ie, the same first name but different last name, date of birth, and medical record number) was scheduled for surgery. Plastic surgery had the highest booking error rate (9, 1.63%) followed by general surgery (47, 1.16%), ophthalmology (9, 1.24%), orthopedics (26, .96%), and vascular surgery (9, .94%) (Fig. 2). Different departments had different types of booking errors. Plastic surgery had mostly wrong-side bookings (5, 56%), whereas general surgery had mostly wrong-approach bookings (16, 43%) (Fig. 3). Most booking errors were caught in the holding area or the OR (122, 81%). The remaining errors were caught in the admitting or assessment areas (28, 18%). Booking errors were discovered throughout the day. Forty (26%) were first cases (discovered from 6:00 AM– 8:59 AM), 43 (28%) were discovered from 9:00 AM to 11:59 AM, and 55 (36%) were discovered in the afternoon (after 12:00 PM). Although the responses of focus group participants varied among and within departments, most of them said that scheduling errors create additional paperwork, reduce the
470
The American Journal of Surgery, Vol 204, No 4, October 2012
Figure 1
Types of scheduling errors.
time they have with patients, and lead to delays and rushing. General surgery cluster participants said wrong-approach bookings happen daily and take an average of 15 to 30 minutes to correct. They added that if these errors occur in
Figure 2
the afternoon, they take even longer to correct because more surgeries are already underway and supplies are limited. The length of delay also depends on whether the necessary equipment is in a different area, floor, or building. Even
Scheduling error rates by department.
R.L. Wu and A.H. Aufses Jr.
Surgical scheduling errors
Figure 3
471
Types of scheduling errors by department.
though booking errors may not always result in a delay, many participants said they found them to be very frustrating. A participant cited a case in which a patient was brought into the OR and anesthetized before the surgical instruments were open and ready. A patient may therefore still enter the OR room on time, but there is a rush to get the proper instruments and recount supplies. Orthopedic cluster participants said that a wrong-side booking sometimes meant that the entire setup of an OR room had to be changed. They estimated that the wrong procedure and incomplete bookings result in the longest delays and take 20 minutes or more to correct. Ophthalmology cluster participants said booking errors can take a few seconds to more than 15 minutes to correct. Many of the participants also cited having to take time out to write the MERS report. In addition, participants said they wanted more feedback from the hospital administration on what measures were being taken to address such errors. Taking into account all surgical departments, including those with whom we did not have focus groups, delays caused by scheduling errors vary from a few minutes to more than 45 minutes. We estimated that if booking errors take an average of 20 minutes to correct, at OR room costs of $16 per minute, each booking error costs at least $320.
Conclusions In this study, we report the frequency of scheduling errors and describe the various types that occur. Although previous studies have analyzed various medical event reporting systems, few have compared paper-based systems with electronic systems.6 –12 We found a significant increase
in scheduling error reporting after the implementation of MERS (P ⬍ .05). It is unclear whether this increase is caused strictly by the change from a paper to electronic system or departmental efforts to increase awareness of the problem. Presentations to OR staff members about booking errors occurred both before and after the implementation of MERS, so they alone do not explain the increase. In addition, the option of anonymity was likely not a contributing factor because all the individuals who submitted the 151 booking errors in MERS included identification. In fact, during focus groups, several participants said they were not wary of including their names and instead wanted more direct feedback from hospital administration. Despite the implementation of MERS, booking errors, like all near misses and adverse events, are probably still underreported.13–17 Electronic-based reporting systems may be a step in the right direction, but further research is necessary to develop better tools to measure the frequency of booking errors and all other near misses and adverse events. Similar to a previous study, we also found that wrongside bookings were the most common booking error reported (55, 36%).4 In addition, however, our study revealed that incomplete and wrong-approach bookings were the second (38, 25%) and third (25, 17%) most common errors to occur. Moreover, different departments were faced with different types of booking errors. Departments such as ophthalmology, otolaryngology, and orthopedics had to address more laterality and site concerns than departments such as general surgery. Wrong-side and wrong-site bookings that are not caught can have devastating consequences for patients and physicians. Although incomplete and wrong-approach bookings are less likely to result in operating on the wrong organ or limb, they are nonetheless a distraction to
472 the entire OR team and can lead to medical errors as well. Incomplete and wrong-approach bookings often lead to a scramble for new instruments and can substantially delay a case. Booking errors discovered during first cases (40, 26%) can be especially detrimental because all subsequent procedures are delayed as well. Incomplete and wrong-approach bookings that occur in the afternoon (55, 36%) are also problematic because more surgeries are underway already and supplies are limited. Any extra OR time needed to correct a booking error can be expensive. To the best of our knowledge, this is the first study to quantify the costs of booking errors. If a booking error takes an average of 20 minutes to correct at our institution, each one costs at least $320. Booking errors that take 45 minutes or more to correct may cost at least $720. These numbers are conservative estimates of the costs of booking errors because we have not included the fees of the surgeon and the anesthesiologist, overtime costs (if a delay occurs and nurses have to stay past their shift), and costs of wasted supplies (if opened, unused supplies are thrown out or have to be resterilized). These estimates are also limited by the information provided during focus groups, and further research is needed to better quantify the costs of booking errors. At MSH, there are five potential areas in which booking errors can be caught: (1) when the patient first arrives and checks in, (2) when the patient is admitted and given an identification band wrapped around the wrist, (3) when the patient is evaluated by the assessment area nurse, (4) when the patient is in the holding area, and (5) when the patient is in the OR. These different stages are focused on collecting and verifying different information. Although the first 2 steps are focused on verifying the patient name, date of birth, and medical record number, the latter 3 stations ask more questions about their medical history, procedure, and side/site of procedure. Despite these 5 checkpoints, most errors are not being discovered until the holding area or the OR (122, 81%). Booking errors that are caught at very late stages can be especially expensive and disruptive. If the error is discovered at the first or second station, a telephone call to the OR can shorten or obviate a delay. Therefore, new systems must be developed to catch scheduling errors as early as possible. Based on their collaboration with 8 health care organizations, the Joint Commission Center for Transforming Healthcare identified 29 main causes of wrong-site surgery, 4 of which occur during the scheduling process.2 These 4 causes were (1) booking documents not verified by office schedulers; (2) schedulers accepting verbal requests for surgical bookings instead of written documents; (3) unapproved abbreviations, cross-outs, and illegible handwriting used on the booking form; and (4) missing consent, history and physical, or surgeon’s orders at the time of booking.2 The center also suggested corresponding solutions for each of these causes.
The American Journal of Surgery, Vol 204, No 4, October 2012 Although there are multiple ways to prevent booking errors based on previous studies and our findings, there are 2 underlying issues that need to be addressed to ensure correct scheduling and surgery. The first issue is to make certain that booking forms are filled out correctly by the physician’s office and the scheduling office. Members of the MSH perioperative staff have identified that miscommunication between the surgeon and the individual scheduling the surgery often led to wrong-side or -site bookings or an incomplete booking. The Minnesota Alliance for Patient Safety addressed this issue by creating a booking form that requires the physician performing the surgery to fill out key sections, such as the procedure and laterality (right, left, or bilateral).5 The Mayo Clinic recently revised their surgical listing computer entry system and found that the booking error rate decreased from 1.50% to .54% (P ⬍ .05) in gynecologic surgery and 2.06% to .49% (P ⬍ .05) in colorectal surgery.4 Even with an electronic system, several checks need to be in place to prevent surgeons or office staff from clicking or selecting the wrong surgery. The second issue is to have additional systems in place to catch more booking errors before they reach the holding area or the OR. To increase the awareness of surgical side/site and other patient safety issues, Johns Hopkins Hospital implemented an OR briefing tool to ensure that the entire OR team understands who the patient is and what procedure is being performed.18 They found that these OR briefings significantly reduced the perceived risk for wrongsite surgery and increased OR team collaboration.19 The Veteran’s Health Administration explicitly outlined what the OR team needed to do during the preoperative verification and “time out” using checklists, and their rate of reported wrong-site surgeries decreased from 3.21 to 2.4 per month (P ⫽ .02).20 In addition to certain required steps, they also made several other recommendations, such as checking the consent form against the OR schedule.21 Although not analyzed in this study, during our datacollection process, we found 10 consent errors reported in the MERS from January 1, 2011, to July 31, 2011. These errors include wrong side or site, wrong procedure, and incomplete consent forms. Having an incorrect or incomplete consent form can lead to greater confusion, whereas if these forms are filled out correctly, they can be used by hospital staff to check against the OR schedule when they need to verify the procedure, side, or site. Although there is no consensus on the best method to reduce the risk of wrong-site surgery, any future initiatives should address the vulnerabilities of the scheduling process. This study shows that booking errors have far-reaching effects and bear substantial financial costs. Previous quality initiatives have not been sufficient, and new systems are needed to buffer against the inherent weaknesses of existing safety checks. Therefore, further research is necessary to better measure the effects and costs of booking errors and to develop tools for more accurate scheduling.
R.L. Wu and A.H. Aufses Jr.
Surgical scheduling errors
References 1. The Joint Commission. Sentinel event statistics as of June 30, 2011. Available at: http://www.jointcommission.org/assets/1/18/SE_Stats_ Summary_2Q_20111.PDF. Accessed September 6, 2011. 2. The Joint Commission, Center for Transforming Healthcare. The wrong site surgery project; 2011. Available at: http://www.center fortransforminghealthcare.org/UserFiles/file/CTH_Wrong_Site_ Surgery_Project_6_24_11.pdf. Accessed September 6, 2011. 3. Schneider ME. Joint commission steps up efforts to reduce wrongsite surgery. American College of Surgeons surgery news. Update 2011, July 15. Available at: http://www.facs.org/surgerynews/update/ wrongsite0711.html. Accessed September 6, 2011. 4. Cima RR, Hale C, Kollengode A, et al. Surgical case listing accuracy: failure analysis at a high-volume academic medical center. Arch Surg 2010;145:641– 6. 5. Minnesota Alliance for Patient Safety. Surgery scheduling and verification project; 2010. Available at: http://www.mnpatientsafety.org/ index.php?option⫽com_content&task⫽view&id⫽88&Itemid⫽0. Accessed September 6, 2011. 6. Flynn EA, Barker KN, Pepper GA, et al. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm 2002;59:436 – 46. 7. Levtzion-Korach O, Alcalai H, Orav EJ, et al. Evaluation of the contributions of an electronic web-based reporting system: enabling action. J Patient Saf 2009;5:9 –15. 8. Milch CE, Salem DN, Pauker SG, et al. Voluntary electronic reporting of medical errors and adverse events. J Gen Intern Med 2006;21:165–70. 9. Chaudhry SI, Olofinboba KA, Krumholz HM. Detection of errors by attending physicians on a general medicine service. J Gen Intern Med 2003;18:595– 600.
473 10. Weingart SN, Callanan LD, Ship AN, et al. A physician-based voluntary reporting system for adverse events and medical errors. J Gen Intern Med 2001;16:809 –14. 11. O’Neil AC, Petersen LA, Cook EF, et al. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med 1993;119:370 –76. 12. Suresh G, Horbar JD, Plsek P, et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics 2004; 113:1609 –18. 13. Evans SM, Berry JG, Smith BJ, et al. Attitudes and barriers to incident reporting: A collaborative hospital study. Qual Saf Health Care 2006; 15:39 – 43. 14. Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract 1999;5:13–21. 15. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine, National Academies Press; 2000. 16. Taylor JA, Brownstein D, Christakis DA, et al. Use of incident reports by physicians and nurses to document medical errors in pediatric patients. Pediatrics 2004;114:729 –35. 17. Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv 1995;21:541– 48. 18. Makary MA, Holzmueller CG, Thompson DA, et al. Operating room briefings: working on the same page. Joint Comm J Qual Patient Saf 2006;32:351–55. 19. Makary MA, Mukherjee A, Sexton JB, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg 2007;204:236 – 43. 20. Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room: A follow-up report. Arch Surg 2011;146:1235–39. 21. Department of Veteran Affairs. Ensuring correct surgery and invasive procedures; 2004. Available at: http://www1.va.gov/vhapublications/ ViewPublication.asp?pub_ID⫽1106. Accessed September 6, 2011.
Clinical Science
Characteristics and costs of surgical scheduling errors Rebecca L. Wu, B.S.a,*, Arthur H. Aufses Jr., M.D.a,b a
Department of Surgery, Mount Sinai Medical Center, 1 Gustave L. Levy Place, New York, NY 10029, USA; bDepartment of Health Evidence and Policy, Mount Sinai Medical Center, New York, NY, USA KEYWORDS: Scheduling errors; Booking errors; Wrong-site surgery; Safety
Abstract BACKGROUND: Errors that increase the risk of wrong-side/-site procedures not only occur the day of surgery but also are often introduced much earlier during the scheduling process. The frequency of these booking errors and their effects are unclear. METHODS: All surgical scheduling errors reported in the institution’s medical event reporting system from January 1, 2011, to July 31, 2011, were analyzed. Focus groups with operating room nurses were held to discuss delays caused by scheduling errors. RESULTS: Of 17,606 surgeries, there were 151 (.86%) booking errors. The most common errors were wrong side (55, 36%), incomplete (38, 25%), and wrong approach (25, 17%). Focus group participants said incomplete and wrong-approach bookings resulted in the longest delays, averaging 20 minutes and costing at least $320. CONCLUSIONS: Although infrequent, scheduling errors disrupt operating room team dynamics, causing delays and bearing substantial costs. Further research is necessary to develop tools for more accurate scheduling. © 2012 Elsevier Inc. All rights reserved.
Wrong-site surgery, including the wrong side, the wrong patient, and the wrong procedure, continues to occur at an alarming rate. It was the most frequently reported sentinel event in 2009 and the third most reported sentinel event in 2010.1 Although the exact incidence and prevalence of wrong-site surgery remain unknown, the Joint Commission estimated a national incidence rate as high as 40 per week.2 The Joint Commission Center for Transforming Healthcare also launched a wrong-site surgery project in 2009 and recently reported that the scheduling process is “ripe for errors.”3 Miscommunication between the surgeon, the individual scheduling the surgery (eg, a secretary or office manager), and the hospital’s scheduling office can easily result in incorrect or Supported by the Mount Sinai School of Medicine’s Summer Research Scholars Program. Rebecca L. Wu is a second year medical student. * Corresponding author. Tel.: ⫹1-718-662-8011; fax: ⫹1-212-4232998. E-mail address: [email protected] Manuscript received October 3, 2011; revised manuscript December 20, 2011
0002-9610/$ - see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2012.01.011
incomplete bookings. The Joint Commission’s project found that in 39% of cases errors that increased the risk of wrong-site surgery were introduced during the scheduling process.3 A few institutions have already implemented changes to their booking process. The Mayo Clinic studied surgical case listing accuracy at their medical center in 2008 and introduced changes to their surgery computer entry system.4 The Minnesota Alliance for Patient Safety initiated a surgery scheduling and verification project in 2009.5 Although these efforts begin to address the problems that can occur during the scheduling process, booking errors and the extent of their effects are still not well understood. This study analyzes the characteristics of booking errors and their impact on operating room staff and costs. Based on our findings, we also discuss potential solutions.
Methods Mount Sinai Hospital (MSH) is a tertiary care academic hospital with 49 operating rooms. We analyzed data from the
R.L. Wu and A.H. Aufses Jr. Table 1
Surgical scheduling errors
469
Laterality/site scheduling errors under a paper versus electronic reporting system*
Number of scheduling errors reported (related to laterality or site) Number of scheduled surgeries performed Error rate (%)
Paper reporting system
Electronic reporting system (MERS)
January 1, 2009–July 31, 2009 41
January 1, 2011–July 31, 2011 66
17, 053 .24
17, 606 .37
P value
.024
*The electronic reporting system, MERS, was implemented in the ORs in March 2010.
MSH electronic medical event reporting system (MERS) from January 1, 2011, to July 31, 2011. This database was implemented in the operating rooms (ORs) in March 2010. Nurses, physicians, and other staff members can submit reports anonymously or with identification. Information collected included the date and time an error occurred, a description of the error, and the location where the error was discovered or reported. To calculate an error rate, we obtained the total number of scheduled surgeries performed from MSH Perioperative Services. We also compared this error rate with the booking error rate under a paper-based medical event reporting system at MSH from January 1, 2009, to July 31, 2009. All the paper reports had to be signed by the individual submitting them. The paper-based reporting system only had records of booking errors related to laterality or site, so only the corresponding cases in 2011 (wrong side/site or missing side/site) were used for this comparison. To study the effects of scheduling errors, we held 3 focus groups with OR nurses and technicians. The focus groups consisted of OR nurses and technicians from the general surgery cluster (8 participants), orthopedics cluster (13 participants), and ophthalmology cluster (5 participants). During the focus groups, participants were asked questions such as (1) “What types of booking errors have you encountered?” (2) “How often do you encounter these types of booking errors?” (3) “What effects do booking errors have?” and (4) “How long does it take for these booking errors to be corrected?” The average delay because of booking errors was estimated based on the numbers cited during these focus groups. OR cost data were also provided by MSH Perioperative Services. To estimate the OR room costs per minute, we divided the general OR costs per hour, $968, by 60 to get $16 per minute. The OR costs include the salaries of OR nurses, technicians, and support staff; the costs of disposable supplies; and the costs of minor equipment (excludes the costs of capital equipment). The surgeon’s and anesthesiologist’s fees were not included. This per-minute calculation was used to estimate the average costs of scheduling errors. MSH’s Institutional Review Board determined that this study did not meet the definition of human subjects research and therefore did not require their review or approval.
Results There was a significant increase in the reporting of laterality or site scheduling errors from the paper-based re-
porting system in 2009 to the electronic reporting system (MERS) in 2011. The error rate from January 1, 2009, to July 31, 2009, was .24% (41) compared with an error rate of .37% (55) from January 1, 2011, to July 31, 2011 (P ⬍ .05) (Table 1). Although MERS reports can be submitted anonymously (unlike the paper reports), all the booking errors were submitted with identification. From January 1, 2011, to July 31, 2011, there were 151 booking errors (.86%) reported out of 17,606 scheduled surgeries. No wrong-site surgeries occurred. The most common type of error was wrong-side booking (55, 36%) followed by incomplete booking (38, 25%), wrong approach (25, 17%), wrong procedure (14, 9%), wrong site (7, 5%), wrong patient information (7, 5%), missing side (3, 2%), wrong procedure and wrong side (1, 1%), and wrong patient (1, 1%) (Fig. 1). Incomplete bookings consisted of cases in which additional procedures (eg, diagnostic laparoscopy, cystoscopy, or ureteral stent placement) were added or bilateral cases were scheduled only on 1 side. Missing-side bookings consisted of cases that did not indicate any side. Wrong-approach bookings involved a change in approach (eg, from laparoscopic to open or open to laparoscopic) before making any incisions. Bookings with the wrong patient information had the wrong date of birth, the wrong medical record number, or a misspelled name. There was 1 wrong patient booking in which the wrong patient (ie, the same first name but different last name, date of birth, and medical record number) was scheduled for surgery. Plastic surgery had the highest booking error rate (9, 1.63%) followed by general surgery (47, 1.16%), ophthalmology (9, 1.24%), orthopedics (26, .96%), and vascular surgery (9, .94%) (Fig. 2). Different departments had different types of booking errors. Plastic surgery had mostly wrong-side bookings (5, 56%), whereas general surgery had mostly wrong-approach bookings (16, 43%) (Fig. 3). Most booking errors were caught in the holding area or the OR (122, 81%). The remaining errors were caught in the admitting or assessment areas (28, 18%). Booking errors were discovered throughout the day. Forty (26%) were first cases (discovered from 6:00 AM– 8:59 AM), 43 (28%) were discovered from 9:00 AM to 11:59 AM, and 55 (36%) were discovered in the afternoon (after 12:00 PM). Although the responses of focus group participants varied among and within departments, most of them said that scheduling errors create additional paperwork, reduce the
470
The American Journal of Surgery, Vol 204, No 4, October 2012
Figure 1
Types of scheduling errors.
time they have with patients, and lead to delays and rushing. General surgery cluster participants said wrong-approach bookings happen daily and take an average of 15 to 30 minutes to correct. They added that if these errors occur in
Figure 2
the afternoon, they take even longer to correct because more surgeries are already underway and supplies are limited. The length of delay also depends on whether the necessary equipment is in a different area, floor, or building. Even
Scheduling error rates by department.
R.L. Wu and A.H. Aufses Jr.
Surgical scheduling errors
Figure 3
471
Types of scheduling errors by department.
though booking errors may not always result in a delay, many participants said they found them to be very frustrating. A participant cited a case in which a patient was brought into the OR and anesthetized before the surgical instruments were open and ready. A patient may therefore still enter the OR room on time, but there is a rush to get the proper instruments and recount supplies. Orthopedic cluster participants said that a wrong-side booking sometimes meant that the entire setup of an OR room had to be changed. They estimated that the wrong procedure and incomplete bookings result in the longest delays and take 20 minutes or more to correct. Ophthalmology cluster participants said booking errors can take a few seconds to more than 15 minutes to correct. Many of the participants also cited having to take time out to write the MERS report. In addition, participants said they wanted more feedback from the hospital administration on what measures were being taken to address such errors. Taking into account all surgical departments, including those with whom we did not have focus groups, delays caused by scheduling errors vary from a few minutes to more than 45 minutes. We estimated that if booking errors take an average of 20 minutes to correct, at OR room costs of $16 per minute, each booking error costs at least $320.
Conclusions In this study, we report the frequency of scheduling errors and describe the various types that occur. Although previous studies have analyzed various medical event reporting systems, few have compared paper-based systems with electronic systems.6 –12 We found a significant increase
in scheduling error reporting after the implementation of MERS (P ⬍ .05). It is unclear whether this increase is caused strictly by the change from a paper to electronic system or departmental efforts to increase awareness of the problem. Presentations to OR staff members about booking errors occurred both before and after the implementation of MERS, so they alone do not explain the increase. In addition, the option of anonymity was likely not a contributing factor because all the individuals who submitted the 151 booking errors in MERS included identification. In fact, during focus groups, several participants said they were not wary of including their names and instead wanted more direct feedback from hospital administration. Despite the implementation of MERS, booking errors, like all near misses and adverse events, are probably still underreported.13–17 Electronic-based reporting systems may be a step in the right direction, but further research is necessary to develop better tools to measure the frequency of booking errors and all other near misses and adverse events. Similar to a previous study, we also found that wrongside bookings were the most common booking error reported (55, 36%).4 In addition, however, our study revealed that incomplete and wrong-approach bookings were the second (38, 25%) and third (25, 17%) most common errors to occur. Moreover, different departments were faced with different types of booking errors. Departments such as ophthalmology, otolaryngology, and orthopedics had to address more laterality and site concerns than departments such as general surgery. Wrong-side and wrong-site bookings that are not caught can have devastating consequences for patients and physicians. Although incomplete and wrong-approach bookings are less likely to result in operating on the wrong organ or limb, they are nonetheless a distraction to
472 the entire OR team and can lead to medical errors as well. Incomplete and wrong-approach bookings often lead to a scramble for new instruments and can substantially delay a case. Booking errors discovered during first cases (40, 26%) can be especially detrimental because all subsequent procedures are delayed as well. Incomplete and wrong-approach bookings that occur in the afternoon (55, 36%) are also problematic because more surgeries are underway already and supplies are limited. Any extra OR time needed to correct a booking error can be expensive. To the best of our knowledge, this is the first study to quantify the costs of booking errors. If a booking error takes an average of 20 minutes to correct at our institution, each one costs at least $320. Booking errors that take 45 minutes or more to correct may cost at least $720. These numbers are conservative estimates of the costs of booking errors because we have not included the fees of the surgeon and the anesthesiologist, overtime costs (if a delay occurs and nurses have to stay past their shift), and costs of wasted supplies (if opened, unused supplies are thrown out or have to be resterilized). These estimates are also limited by the information provided during focus groups, and further research is needed to better quantify the costs of booking errors. At MSH, there are five potential areas in which booking errors can be caught: (1) when the patient first arrives and checks in, (2) when the patient is admitted and given an identification band wrapped around the wrist, (3) when the patient is evaluated by the assessment area nurse, (4) when the patient is in the holding area, and (5) when the patient is in the OR. These different stages are focused on collecting and verifying different information. Although the first 2 steps are focused on verifying the patient name, date of birth, and medical record number, the latter 3 stations ask more questions about their medical history, procedure, and side/site of procedure. Despite these 5 checkpoints, most errors are not being discovered until the holding area or the OR (122, 81%). Booking errors that are caught at very late stages can be especially expensive and disruptive. If the error is discovered at the first or second station, a telephone call to the OR can shorten or obviate a delay. Therefore, new systems must be developed to catch scheduling errors as early as possible. Based on their collaboration with 8 health care organizations, the Joint Commission Center for Transforming Healthcare identified 29 main causes of wrong-site surgery, 4 of which occur during the scheduling process.2 These 4 causes were (1) booking documents not verified by office schedulers; (2) schedulers accepting verbal requests for surgical bookings instead of written documents; (3) unapproved abbreviations, cross-outs, and illegible handwriting used on the booking form; and (4) missing consent, history and physical, or surgeon’s orders at the time of booking.2 The center also suggested corresponding solutions for each of these causes.
The American Journal of Surgery, Vol 204, No 4, October 2012 Although there are multiple ways to prevent booking errors based on previous studies and our findings, there are 2 underlying issues that need to be addressed to ensure correct scheduling and surgery. The first issue is to make certain that booking forms are filled out correctly by the physician’s office and the scheduling office. Members of the MSH perioperative staff have identified that miscommunication between the surgeon and the individual scheduling the surgery often led to wrong-side or -site bookings or an incomplete booking. The Minnesota Alliance for Patient Safety addressed this issue by creating a booking form that requires the physician performing the surgery to fill out key sections, such as the procedure and laterality (right, left, or bilateral).5 The Mayo Clinic recently revised their surgical listing computer entry system and found that the booking error rate decreased from 1.50% to .54% (P ⬍ .05) in gynecologic surgery and 2.06% to .49% (P ⬍ .05) in colorectal surgery.4 Even with an electronic system, several checks need to be in place to prevent surgeons or office staff from clicking or selecting the wrong surgery. The second issue is to have additional systems in place to catch more booking errors before they reach the holding area or the OR. To increase the awareness of surgical side/site and other patient safety issues, Johns Hopkins Hospital implemented an OR briefing tool to ensure that the entire OR team understands who the patient is and what procedure is being performed.18 They found that these OR briefings significantly reduced the perceived risk for wrongsite surgery and increased OR team collaboration.19 The Veteran’s Health Administration explicitly outlined what the OR team needed to do during the preoperative verification and “time out” using checklists, and their rate of reported wrong-site surgeries decreased from 3.21 to 2.4 per month (P ⫽ .02).20 In addition to certain required steps, they also made several other recommendations, such as checking the consent form against the OR schedule.21 Although not analyzed in this study, during our datacollection process, we found 10 consent errors reported in the MERS from January 1, 2011, to July 31, 2011. These errors include wrong side or site, wrong procedure, and incomplete consent forms. Having an incorrect or incomplete consent form can lead to greater confusion, whereas if these forms are filled out correctly, they can be used by hospital staff to check against the OR schedule when they need to verify the procedure, side, or site. Although there is no consensus on the best method to reduce the risk of wrong-site surgery, any future initiatives should address the vulnerabilities of the scheduling process. This study shows that booking errors have far-reaching effects and bear substantial financial costs. Previous quality initiatives have not been sufficient, and new systems are needed to buffer against the inherent weaknesses of existing safety checks. Therefore, further research is necessary to better measure the effects and costs of booking errors and to develop tools for more accurate scheduling.
R.L. Wu and A.H. Aufses Jr.
Surgical scheduling errors
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