Joint Commission revises universal protocol, clarifies who marks site
Joint Commission revises universal protocol, clarifies who marks site
Despite being pressured, The Joint Commission (TJC) has not dictated in the revised "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery" that surgeons must be the ones who mark the surgical site.
At a summit last year on wrong-site surgery, pressure was put on TJC to have the surgeon mark the site, says Peter Angood, MD, vice president and chief patient safety officer for TJC. "But we recognize that individuals needed a little flexibility in trying to be efficient with OR time and need to accommodate education and training programs and cross-covering of procedures among members of a group practice."
The revised protocol is part of the 2009 National Patient Safety Goals (NPSGs). The revised universal protocol will be one of the biggest challenges for outpatient surgery programs, along with the new goal on reducing surgical-site infections, Angood says. The revisions to the universal protocol grew out of concerns that the number of wrong-site incidents have not decreased, sources say.
Kate Moses, RN, CNOR, CPHQ, quality management nurse at Medical Arts Surgery Centers (MASC) in Miami, says misinterpretation of the protocol was not a problem at her facility, but it was elsewhere. "A lot of people interpreted the universal protocol the way that thought it should be, not necessarily the way that it was," she says. "Everyone was doing their own thing and not being consistent with other parts of their own health system, never mind other unrelated entities."
MASC has made the timeout mandatory, with nurses mandated to call the timeout, Moses says. A charge nurse or designee monitors one case daily for compliance with the timeout requirement. The results are tracked and posted. MASC has reached 100% compliance, as well as 100% compliance with documentation of the timeout in the OR record.
William Beaumont Hospital in Royal Oak, MI, has implemented a more detailed "briefing" approach to the timeout. The briefing includes a discussion, for example, of antibiotics, blood needed, blood availability, and special instruments, as well as the timeout. "It's to promote safety," says Allynn Petersen, RN, CNOR, MS, administrative director of surgical services.
To ensure the right implant is available for the right patient, Moses' facility implemented the step of having the surgeon check the implant before scrubbing. "Once you scrub, you can't do a hands-on looking at the package," she says. MASC keeps implants locked up, except for the one for the current case, Moses says. She knows of facilities that have implanted the wrong lens, which meant the patient had to come back for another procedure. Sometimes the lens was the wrong brand, and sometimes it was more expensive, Moses says. "It may not affect the patient on a long-term basis, but it affects the institution," she says.
In one reported case, an OR team had several cases scheduled and had all of the lenses for the day's cases available, says Mark Mayo, corporate director of ASC operations for Magna Health Systems in Chicago and executive director of the Surgery Center Association of Illinois. One patient canceled, and the staff failed to verify the patient for the following case, he says. Instead, a staff person grabbed the lens meant for the canceled patient, and it was implanted on the wrong patient, The wrong lenses subsequently were implanted on all of the patients who followed, Mayo adds.
Providers say checklists work well as a tool to avoid wrong-patient or wrong-site surgery. Beaumont has a checklist with sections for the anesthesia provider, circulating nurse, pre-op nurse, and surgeon to complete before the procedure, Petersen says. The World Health Organization has just developed a new safety checklist for surgical teams to use in ORs. (See checklist. To download the implementation manual or an electronic copy of the checklist, go to www.who.int.)
Will the revised protocol help reduce incidents of wrong-site surgery? Moses hopes so. "You still have the human factor," she says. "You still have the need to rely on everyone doing their part."
Everyone should be comfortable speaking up if there is a problem, managers say. Beaumont Hospital offered assertiveness training to their OR staff. "We wanted everyone to be comfortable stopping 'the line' at any point," says Petersen.
Consider having the verification during the timeout procedure performed by the OR nurse and anesthetist first, and the surgeon last, Mayo suggests. "When the surgeon states first that everything is OK, everyone else has a tendency to say, 'Yes, doctor," and not catch the mistake," he says.
Outpatient surgery may be particularly at risk for wrong-site surgery because providers are rushing, some sources say.
"Everyone is in a hurry," Moses says. Some have a philosophy that "time is money," she says. "Others take as much time as they need and do double-checks," Moses says. "Those are the people who probably will never have to have a bad night's sleep about what they've done for that day." (Editor's note: For the complete list of 2009 National Patient Safety Goals for hospitals, ambulatory care facilities, and office-based surgery, go to www.jointcommission.org.)
Despite being pressured, The Joint Commission (TJC) has not dictated in the revised "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery" that surgeons must be the ones who mark the surgical site.Subscribe Now for Access
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