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Fairview scores perfect zero on hospital error report

The next time you go in for a procedure at Fairview Red Wing Medical Center, expect to be treated less like a patient and more like an airline passenger.

Medical staff are adopting procedures more akin to flying a plane than to the sometimes hurried assembly line medicine of the past, medical center officials said.

"We're changing the systems to try to eliminate human error," said Dr. Beth Thomas, Fairview's chief of surgery.

One mark of success is that Fairview did not have a single "adverse event" reported in the Minnesota Department of Health's annual report on hospital incidents released Thursday, covering October 2006 to October 2007.

Adverse events include such things as pressure ulcers, objects left in the body after surgery, operating on the wrong body part or doing the wrong procedure, death or disability from medication errors, or death from a fall.

Fairview made the list in each of the three previous years since it began coming out. Lake City Medical Center reported one adverse event last year, a surgery performed on the wrong body part.

Fairview brought in experts on human error from the University of Minnesota last April to study operating room procedures in particular.

"Psychologists came and did a visual inspection of what we were doing, then did a report on the things that they observed," said Jane McNamara, R.N., director of surgery. "They told us what they felt we needed to correct. They identified the issues, and we developed the solutions."

Thomas said those solutions include counting -- out loud -- every item in the operating room before a surgical procedure. The items are counted again later to make sure nothing ends up inside the patient.

Solutions also include "site marking," in which the surgeon comes in before the procedure and initials the body part to be operated on so there is no confusion about what is to be done or who is to do it.

And the operating room culture has been changed to involve everyone in the room, Thomas said. If anyone on the team suspects anything is not right, they can call a "hard stop" to verbally review what is going on, she said.

The new systems are similar to what occurs in the cockpit of an airplane before takeoff as the pilot and co-pilot go over a lengthy checklist and make sure the aircraft is operating properly.

"We're being very rigorous," Thomas said. "There's no drift. We're becoming very specific about how we do things and standardizing process to the point that we know it feels wrong."

Thomas said the aim is to extend the new system beyond the operating room to every aspect of Fairview's medical care.

McNamara admitted all that counting and accounting takes more time than previously.

"It takes more time, but once the process becomes ingrained, we'll see some of that time subside," she said.

Thomas said another change is that if an adverse patient incident should occur, the new priority is to first comfort the patient and family.

"If an error occurs, our number one concern is the comfort the patient and family, and number two to look at the process and how to fix it so it never happens again," Thomas said.

Adverse events that do occur are now discussed across the 197 facilities in the Minnesota Hospital Association, Thomas said, so all hospitals can learn what is and what isn't working.

"The more checks, the better it is for the patient," McNamara said.

"And if we have something happen, we will learn from it."