"We give employees and front line staff the opportunity to speak up and say so whenever they're uncomfortable with a situation or direction," she says.
Mark Chassin, MD, president of the Joint Commission, also discouraged hospitals from making a massive jump to employ videography in the surgical suite.
"There are a lot of process that takes place prior to the patient's arrival in the operating room, and those parts of the process need to be perfected as well as the last part of the process in the operating room," he says. "I don't think it (videography) is a necessary step. And, as Mary [Cooper] suggests, it can be helpful if individual organizations think that kind of auditing or additional information could help them pinpoint problems.”
The eight organizations that participated in the wrong-site surgery examination process "have shown that we can identify areas where the risk of this problem is introduced ... and we can develop tools to drastically reduce that risk without having to invest in a huge number of video cameras," Chassin said.
The task force identified high-risk practices that Cooper and others believe are far more important to change if surgical errors, such as wrong-site surgery, are to be fixed. Some of these practices have nothing to do with what happens in the hospital at all.
As Chassin says. A beginning-to-end examination needs to occur. Errors creep into the process in the physician's office when the patient is being scheduled for surgery and during the transmittal of the patient's record from a nurse or clerical employee to the hospital surgical scheduler. Then, there are opportunities for error in the pre-operative phase of the patient's visit.
The toolkit developed by the Joint Commission effort lists 29 scheduling and surgical practices that put hospitals and their patients at higher risk for a error such as wrong-site surgery.
And after each flaw, the toolkit enumerates remedies to remove those risks. And it's a long one. But Cooper and others say that fixing these problems, much more than installing eyes in hospital surgical suite ceilings, will be much more likely to reduce mistakes.
I say that if a family member or a patient insists on a video camera, let them have it and let them pay the additional cost. But for now, there are much better ways to stop surgical errors by making it almost impossible for them to happen in the first place.