Effective strategies to comply with Joint Commission’s universal protocol

Is your plan to avoid surgical mistakes really foolproof?

It’s every quality manager’s worst nightmare: Your facility is the lead story on tonight’s news because the wrong person was operated on. "These days, if you operate on the wrong patient or do the wrong procedure, you’re going to be on the front page of the newspaper," warns DeNene G. Cofield, RN, BSN, CNOR, administrative director of surgical services at Medical Center East in Birmingham, AL.

To address this, the Joint Commission on Accreditation of Healthcare Organizations has approved a "Universal Protocol for Preventing Wrong-Site, Wrong-Procedure, and Wrong-Person Surgery." The requirement, which applies to all surgical and invasive procedures, becomes effective July 2004.

Above all, the key to preventing surgical mistakes is to implement a team approach, says Jodi L. Eisenberg, CPHQ, CMSC, coordinator for accreditation and licensure for quality strategies at Northwestern Memorial Hospital in Chicago. "No one person can take this responsibility," she says. "A policy and procedure must be put into place that is followed consistently by all of the team members."

For quality managers, one of the best ways to help perioperative services comply is to share actual examples of near misses and sentinel events, Eisenberg suggests. "Everyone thinks, It won’t happen to me.’ But it continues to happen."

Your No. 1 priority is to bring home the importance of this to every staff member, Cofield says. As a result, the universal protocol requirements now are included in general orientation for nursing and hospital staff and are continually reviewed at staff meetings. "One thing we learned is that a one-time inservice doesn’t cut it," she says. "If leaders aren’t constantly talking about safety, then the staff are, perhaps, going to let it become a second-level concern."

Initially, some physicians were reluctant to participate in the universal protocol’s requirements, Cofield acknowledges. "There was a general lack of knowledge about the true intent of the protocol. We addressed that with education," she says. "There is nothing like knowledge-based information."

By and large, medical staff have been very supportive, with the exception of a few who ultimately were won over, she reports. This was accomplished by discussing patient safety at every medical staff, committee, and professional meeting, Cofield explains.

Media stories and published studies are brought to light, to underscore the reality of the problem, she adds. "I think it helps everyone to appreciate the prevalence of issues occurring. With that understanding comes better compliance."

The biggest obstacle to implementing the universal protocol is lack of urgency on the part of physicians and staff, says Christy Dempsey, BSN, CNOR, director of perioperative services at St. John’s Regional Health Center in Springfield, MO. "Most surgeons don’t think this is a problem until it becomes one," she says.

To address this, she recommends role-playing exercises to demonstrate the consequences of not following the safety measures, and the devastation it can cause to patients. A recent scenario involved a fire in the OR caused by a staff member’s placing a Bovie holster on drapes, which caught on fire. Staff were used as actors playing the patient, first scrub, assistant, anesthesia, and circulator.

"Staff learned the details of evacuation and were able to put the policy into action; so that if this were to ever happen, they know exactly what their responsibility is: Who shuts off the gases; what do we do with the wound; how do we actually evacuate the room; who notifies the fire department," she says. "These are things that are probably in every policy book out there. But when it’s actually demonstrated live, it makes a much more lasting impression."

To measure compliance, real-time monitoring is the most optimal, Eisenberg says. She recommends retrospective review of the following:

  • percentage of films taken without sides marked with lead markers;
  • percentage of sites marked by patient (or by caregiver);
  • percentage of preoperative checklists completed;
  • percentage of time-outs prior to incision;
  • percentage side/site noted correctly on consent;
  • "Left" and "right" are spelled out in medical record documentation (pre-, during, and post-procedure), and all are in agreement.

Here are requirements of JCAHO’s universal protocol and effective strategies for each:

1. Preoperative verification process. Nurses go through a preoperative checklist before the patient is taken to the operating room, Cofield says. "This is a process where we are reconciling the findings and results of all aspects of the chart," she explains.

2. Marking of the operative site. Convey to patients that their help is needed with the surgical process, Dempsey advises. "It’s important and recommended by JCAHO that patients and their surgeon actually do the marking," she says. "We have the patient mark the site preoperatively."

To ensure that all patients are marked, there is ongoing monitoring in the holding area for both inpatients and morning admission patients, says Cofield. "If patients haven’t been marked prior to getting to the operating room, we are following up on each of those incidents," she says.

Currently, the facility is considering how to handle patients who refuse site markings, says Cofield. "We’ve had a surgical site marking policy since the mid-1990s and never had a patient refuse, but we’re in dialogue right now about what our policy would be if a patient did refuse," she explains.

In this scenario, the best strategy would be a bedside consult to occur with the physicians and the staff performing the procedure, so everyone in the room understands where the surgical site is located and what the patient’s reluctance to being marked is, she suggests.

The facility has made an "interpretive exception" to following the universal protocol to the letter, notes Cofield, referring to the requirement that the person performing the procedure do the actual marking. This just isn’t feasible, she explains.

This is because so many processes are occurring simultaneously to get the patient ready for surgery, she explains, making it impossible for the surgeon in the OR to do the marking.

Instead, a nurse does the marking with the patient or designated family representative. If a family member isn’t available, two nurses verify the site and do the marking after they have reconciled the consent and the X-rays with the history and physical in the chart.

For spine marking, the staff and patient verbalize what part of the spine they are having surgery on, and mark "yes" at either the cervical, thoracic, or lumbar spine area, and the physician uses the North American Spine Society protocol for determining the specific level floroscopically.

For patients with dark skin, you’ll need a different-colored marker so the word "yes" is clearly visible, notes Cofield. "We had to try a variety of different markers to find some that would show up. We now use a red Sharpie for dark skin."

3. Taking a timeout immediately before the procedure. This is monitored in two different ways, says Cofield. "We have found that just chart review alone isn’t enough, so we are also doing direct observation and quality control checks," she says.

The facility’s staff development coordinator monitors procedures using a checklist, to ensure that staff are adhering to sterile technique during the prepping and draping process, and that surgical timeout occurred at a standardized time and included all members of the surgical team, including the physician, anesthesiologist and the nursing staff, and that this is documented, Cofield says.

Staff are surveyed as to whether they actually are implementing the surgical timeout, and whether they are encountering any reluctance or backlash from other members of the health care team, Cofield says.

The first survey included just the OR staff, whereas a second survey was sent to the staff in the morning admission area in addition to the OR, she says. "A third survey will include the nursing staff on floor," says Cofield. "We are really trying to reach outside the operating room."

The following steps are taken for the surgical timeout before a procedure occurs:

  • The patient’s X-rays are placed on the view box, and the patient’s chart is opened to the consent form.
  • When the nurse finishes preparing the patient, the timeout occurs when the surgeon and anesthesiologist both are in the room.
  • The nurse verifies the site marking is there, reads the name of the patient and the procedure, and holds the consent up for everyone in the room to acknowledge.
  • Nurses document that the timeout has occurred.

4. Adaptation of the requirements to nonoperating room settings, including bedside procedures. The timeout process is adapted for bedside procedures by keeping a copy of the chart and consent at the bedside, Cofield says. "Those procedures may not have an X-ray, so the process is to mark the site with the patient, and verbalize the patient’s name and procedure with the surgeon present," she says.

[For more information on JCAHO’s universal protocol, contact:

DeNene G. Cofield, RN, BSN, CNOR, Administrative Director of Surgical Services, Medical Center East, 50 Medical Center E., Birmingham, AL 35235. Telephone: (205) 838-3560. E-mail: DGCofield@ehs.inc.com.

Christy Dempsey, BSN, CNOR, Director of Perioperative Services, St. John’s Regional Health Center, 1235 E. Cherokee St., Springfield, MO 65804. Telephone: (417) 820-2302. Fax: (417) 888-7793. E-mail: CDempsey@sprg.smhs.com.

Jodi L. Eisenberg, CPHQ, CMSC, Coordinator, Accreditation & Licensure Quality Strategies, Northwestern Memorial Hospital, 676 St. Clair, Suite 700, Room 7-005, Chicago, IL 60611. Telephone: (312) 926-5705. E-mail: jeisenbe@nmh.org.]