Patient Safety in Neurosurgery.ppt
Patient Safety in Neurosurgery,Interactive MOC ProgramAANS/ABNS2011,Module 1Part 1,TORRES F3098890,TORRES F3098890,TORRES F3098890,TORRES F3098890,TORRES F3098890,TORRES F3098890,Overview,The following MOC exercise is composed of two sections:An animated patient care scenario in which Dr.Anderson,a junior neurosurgeon,performs an operation at the request of a colleague,Dr.Montpierre,and encounters an error.A followup,interactive module focusing on patient safety aspects of the case and an analysis of the error.,Introduction,The scenario begins with a conversation between Dr.Anderson and Dr.Montpierre during Neurosurgical Grand Rounds,EXIT,Montagemusicstarted 0.8,Another“guerney”ambient noise on bracelet,11 LI L CEA11 LI R VPS12 MONTPIERRE R BRAIN BIOPSY12 MONTPIERRE R BRAIN BIOPSY13 CHAO L4-5 TLIF13 CHAO C3-7 LAMI14 PATIL L CRANI14 PATIL R CRANI15 MONTPIERRE R BRAIN BIOPSY,OR 10-11OR 12-15,Stall time,Stall time,11 LI L CEA11 LI R VPS12 MONTPIERRE R BRAIN BIOPSY12 MONTPIERRE R BRAIN BIOPSY13 CHAO L4-5 TLIF13 CHAO C3-7 LAMI14 PATIL L CRANI14 PATIL R CRANI15 MONTPIERRE,11 LI L CEA11 LI R VPS12 MONTPIERRE R BRAIN BIOPSY12 MONTPIERRE R BRAIN BIOPSY13 CHAO L4-5 TLIF13 CHAO C3-7 LAMI14 PATIL L CRANI14 PATIL R CRANI15 MONTPIERRE,TORRES,LUCITA3583672,11 LI L CEA11 LI R VPS12 MONTPIERRE R BRAIN BIOPSY12 MONTPIERRE R BRAIN BIOPSY13 CHAO L4-5 TLIF13 CHAO C3-7 LAMI14 PATIL L CRANI14 PATIL R CRANI15 MONTPIERRE,11 LI L CEA11 LI R VPS12 MONTPIERRE R BRAIN BIOPSY12 MONTPIERRE R BRAIN BIOPSY13 CHAO L4-5 TLIF13 CHAO C3-7 LAMI14 PATIL L CRANI14 PATIL R CRANI15 MONTPIERRE,11 LI L CEA11 LI R VPS12 MONTPIERRE R BRAIN BIOPSY12 MONTPIERRE R BRAIN BIOPSY13 CHAO L4-5 TLIF13 CHAO C3-7 LAMI14 PATIL L CRANI14 PATIL R CRANI15 MONTPIERRE,L CEAR VPS R BRAIN R BRAIN L4-5 TLIFC3-7 LAMIL CRANI15 MONTPIERRE R BRAIN BIOPSY,11 LI L CEA11 LI R VPS12 MONTPIERRE R BRAIN BIOPSY12 MONTPIERRE R BRAIN BIOPSY13 CHAO L4-5 TLIF13 CHAO C3-7 LAMI14 PATIL L CRANI14 PATIL R CRANI15 MONTPIERRE,11 LI L CEA11 LI R VPS12 MONTPIERRE R BRAIN BIOPSY12 MONTPIERRE R BRAIN BIOPSY13 CHAO L4-5 TLIF13 CHAO C3-7 LAMI14 PATIL L CRANI14 PATIL R CRANI15 MONTPIERRE,11 LI L CEA11 LI R VPS12 MONTPIERRE R BRAIN BIOPSY12 MONTPIERRE R BRAIN BIOPSY13 CHAO L4-5 TLIF13 CHAO C3-7 LAMI14 PATIL L CRANI14 PATIL R CRANI15 MONTPIERRE R BRAIN BIOPSY,11 LI L CEA11 LI R VPS12 MONTPIERRE R BRAIN BIOPSY12 MONTPIERRE R BRAIN BIOPSY13 CHAO L4-5 TLIF13 CHAO C3-7 LAMI14 PATIL L CRANI14 PATIL R CRANI15 MONTPIERRE R BRAIN BIOPSY,Great lets get started,TORRES,LOU 309889038M 12/24/72,TORRES,LOU 309889038M 12/24/72,DEPARTMENT OFPATHOLOGY,EXIT,TORRES,LOU 309889038M 12/24/72,OH NO!WHAT HAVE I DONE?,Dr.Anderson has discovered that an error has occurred.Help him locate the information which produced it and identify the mistake.,By clicking“continue”below,you will enter an“EXPLORE”screen,and have a chance to review scenes from the scenario and search for information which can be used to identify the error which occurred and its cause.You will have unlimited time to review the information in the selected scene frames but cannot exit the“EXPLORE”page for a least 1 minute.Once you have arrived at a hypothesis regarding the nature of the error click the green“EXIT”bar.You will then have a chance to choose from among a set of potential errors the one that best matches your analysis of the scenario.If you choose incorrectly,you have the option of replaying the animated scenario from the beginning or studying the“EXPLORE”page again.,INTERACTIVE COMPONENT INSTRUCTIONS,CONTINUE,REPLAY MOVIE,TIME ELAPSED,Click an image below to explore.,EXIT:click here when youve found out what went wrong.,REPLAY MOVIE,WHAT WENT WRONG?Click your answer.,The navigation software must be broken!,The pathology lab mixed up the sample.,Im operating on the wrong side!,The biopsy needle isnt working right.,The lesion must have regressed.,Im operating on the wrong patient!,Im doing the wrong procedure!,I have no idea.Need to explore more.GO BACK,WHAT WENT WRONG?Click your answer.,The navigation software must be broken!,The pathology lab mixed up the sample.,Im operating on the wrong side!,The biopsy needle isnt working right.,The lesion must have regressed.,Im doing the wrong procedure!,NOT THIS TIME.Theres a better explanation.Take a little time to explore some more.,I have no idea.Need to explore more.GO BACK,Im operating on the wrong patient!,TIME ELAPSED,Click an image below to explore.,EXIT:click here when youve found out what went wrong.,REPLAY MOVIE,WHAT WENT WRONG?Click your answer.,The navigation software must be broken!,The pathology lab mixed up the sample.,Im operating on the wrong side!,The biopsy needle isnt working right.,The lesion must have regressed.,Im operating on the wrong patient!,Im doing the wrong procedure!,I have no idea.Need to explore more.GO BACK,WHAT WENT WRONG?Click your answer.,Im operating on the wrong patient!,CORRECT!,Wrong patient surgery,Dr.Anderson operated on the wrong patient(the wrong Torres).The mistake was the result of overlooking a mismatch between radiographic materials and identifiers traveling with the patient.In this scenario,Dr.Anderson reviews radiographs that belong to a different patient with the same last name.The surgeon could have avoided this problem had he been more careful about matching all pieces of patient specific information.,CONTINUE,Wrong patient surgery,Several clues to the identity mismatch were presented,including:The name and number on the patients ID bracelet differ from those on the navigation imageBirthdate on the consent form differs from that on both the print film and navigation imageDifferent gender data on the consent and navigation annotation,CONTINUE,Wrong patient surgery,Although it would have been helpful if Dr.Andersons colleague had alerted him to the presence of two patients sharing the same last name,the attending surgeon is still responsible for the complete review of all patient-specific pieces of information.As this case shows,a single crucial mismatch of information one not always visualized during routine timeout procedures can produce an error in treatment.The only safeguard against this sort of error is diligence on the part of the responsible physician(which may falter if the physician is distracted or assuming responsibility for a patient under time pressed conditions).,CONTINUE,Coming next,The exercise you just completed illustrates an error traceable to a visible disagreement within an information stream.Errors can also occur if the information stream is temporally interrupted and facts change in an unobserved way,or incorrect information is interpreted as applicable if the context is convincingly plausible.We will explore such types of errors in Parts 2 and 3 of the first module.,STORY DEVELOPMENTLawrence Chin,M.D.Justin Massengale,M.D.James Holsapple,M.D.ANIMATION PRODUCTIONJustin Massengale,M.D.2011,ABNS“Errors”module proposalPart 1,
