Description:

Medical procedure Never Events, such as “wrong patient, wrong procedure, wrong surgical site errors” (WSPEs) occur 40-80 times or more per week in the U.S. Despite of the introduction of the international standards for surgical safety checklists a decade ago, the rate of surgical Never Event continues to increase. We will examine clinical, workflow, and business challenges to eradicating these errors and how clinical informatics may offer a cure for this systemic disease. It is critical to start the safety process earlier, especially in the ambulatory setting where more than 39% of the WSPEs originate, and to include the patient. In our approach, patient safety checklist information is entered by clinicians during intake, stored on HIPAA-compliant cloud servers, sent to patients or parents for online review, and reviewed by preoperative and operative nursing immediately prior to surgery. These checklists generate documents that can be integrated with electronic health records (EHRs). An initial study of 100 consecutive general surgical pediatric operations demonstrates improved parent and clinician satisfaction with the surgical safety process. The next phase, demonstrating reduction of WSPEs, will involve over 10,000 patients.