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1、Patient Safety in NeurosurgeryInteractive MOC ProgramAANS/ABNS2011Module 1Part 1TORRES F3098890TORRES F3098890TORRES F3098890TORRES F3098890TORRES F3098890TORRES F3098890OverviewThe following MOC exercise is composed of two sections: 1)An animated patient care scenario in which Dr. Anderson, a junio
2、r neurosurgeon, performs an operation at the request of a colleague, Dr. Montpierre, and encounters an error.2)A followup, interactive module focusing on patient safety aspects of the case and an analysis of the error.IntroductionThe scenario begins with a conversation between Dr. Anderson and Dr. M
3、ontpierre during Neurosurgical Grand RoundsDr. Montpierres pt Torres wants to meet you before surgeryTORRES FRANK3098890 TORRES L12/24/72TORRES L12/24/72TORRES L12/24/72TORRES L12/24/72TORRES L12/24/72TORRES L12/24/72TORRES L12/24/72TORRES L12/24/72TORRES L12/24/72and three patients waiting for you
4、in clinic ORMENS7654321Montagemusicstarted 0.8Another “guerney” ambient noise on bracelet11 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 BIOPSYMAIN OPERATING ROOMAUTHORIZEDPERSONNEL
5、ONLYOR 10-11OR 12-15Stall timeDr. Montpierres pt Torres wants to meet you before surgeryStall time L CEAR VPS R BRAIN R BRAIN L4-5 TLIFC3-7 LAMIL CRANI15 MONTPIERRE R BRAIN BIOPSY11 LI L CEA11 LI R VPS12 MONTPIERRE R BRAIN BIOPSY12 MONTPIERRE R BRAIN BIOPSY13 CHAO L4-5 TLIF13 CHAO C3-7 LAMI14 PATIL
6、L CRANI14 PATIL R CRANI15 MONTPIERRE R BRAIN BIOPSYTORRES L12/24/72TORRES L12/24/72TORRES L12/24/72TORRES L12/24/72TORRES L3098890TORRES L12/24/72TORRES L12/24/72TORRES L12/24/72TORRES F12/24/72TORRES L12/24/72TORRES L12/24/72TORRES L12/24/72TORRES L12/24/72TORRES L12/24/72TORRES L12/24/72TORRES L12
7、/24/72TORRES L12/24/72TORRES F12/24/72TORRES L12/24/72TORRES L12/24/72TORRES L12/24/72TORRES L12/24/72TORRES L3098890TORRES L12/24/72TORRES L12/24/72TORRES L12/24/72TORRES F12/24/72m11 LI L CEA11 LI R VPS12 MONTPIERRE R BRAIN BIOPSY12 MONTPIERRE R BRAIN BIOPSY13 CHAO L4-5 TLIF13 CHAO C3-7 LAMI14 PAT
8、IL L CRANI14 PATIL R CRANI15 MONTPIERRE R BRAIN BIOPSYGreat lets get startedTORRES, LOU 309889038M 12/24/72TORRES, LOU 309889038M 12/24/72TORRES, 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
9、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 t
10、he 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 t
11、he 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 INSTRUCTIONSCONTINUE REPLAY MOVIETIME ELAPSEDblockClick an image below to explore.The two patients are both biopsies. You ought
12、 to be able to get them done quickly, no?Yeah, easy for you to say. Ive got a full days worth of clinic patients waiting. Wouldve helped if youd given me a little more info.GO BACKGO BACKGO BACKGO BACKGO BACKEXIT: click here when youve found out what went wrong.REPLAY MOVIEGO BACKWHAT WENT WRONG?Cli
13、ck 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 BACKW
14、HAT 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
15、to explore some more.I have no idea. Need to explore more. GO BACKIm operating on the wrong patient!TIME ELAPSEDblockClick an image below to explore.The two patients are both biopsies. You ought to be able to get them done quickly, no?Yeah, easy for you to say. Ive got a full days worth of clinic pa
16、tients waiting. Wouldve helped if youd given me a little more info.GO BACKGO BACKGO BACKGO BACKGO BACKEXIT: click here when youve found out what went wrong.REPLAY MOVIEGO BACKWHAT WENT WRONG?Click your answer.The navigation software must be broken!The pathology lab mixed up the sample.Im operating o
17、n 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 BACKWHAT WENT WRONG?Click your answer.Im operating on the wrong patient!CORRECT!Wrong patient surgeryDr. Anders
18、on 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 surg
19、eon could have avoided this problem had he been more careful about matching all pieces of patient specific information.CONTINUE Wrong patient surgerySeveral clues to the identity mismatch were presented, including:The name and number on the patients ID bracelet differ from those on the navigation im
20、ageBirthdate on the consent form differs from that on both the print film and navigation imageDifferent gender data on the consent and navigation annotationCONTINUE Wrong patient surgeryAlthough it would have been helpful if Dr. Andersons colleague had alerted him to the presence of two patients sha
21、ring 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 o
22、nly 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 nextThe exercise you just completed illustrates an error traceable t
23、o 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. 2011ABNS “Errors” module proposalPart 1
