Kaiser hospital vows to enforce Universal Protocol

A San Francisco hospital is taking the Universal Protocol so seriously that it has threatened to suspend entire operative teams — the surgeon, anesthesiologist, nurses, and anyone else in the room — if the procedures to prevent wrong-site surgery are not followed. The warning was recently issued at Kaiser Foundation Hospital, where Linda Groah, RN, is chief nurse executive and director of hospital operations. She also is past president of the Association of periOperative Registered Nurses. "My medical center has taken a very firm stand on this. We believe this is a team effort," she says. "It starts with the anesthesiologist, the person we have delegated the responsibility for declaring a timeout, and then the rest of the team is to join in."

If the anesthesiologist does not take the lead for some reason, the circulating nurse or the surgeon must call the timeout, Groah says. Ultimately, every person in the operating room is expected to speak up if the procedure is about to begin and no one has called a timeout. And once a timeout is called, it is mandatory that each person participate. "If all of the team members do not take part in this timeout or they do not implement the time out, the privileges for the surgeon are suspended and the entire team is suspended, the nurses and the anesthesiologist also. That’s how strongly we believe in this Universal Protocol."

That may sound like a tough stance, but Groah says it is supposed to. She says the hospital has shifted from a "no-blame culture" to what it calls a "just culture" that requires accountability and responsibility for following policies and procedures that protect the patient.

"If anyone sees anything happening that is not as it should be, they have a responsibility to put a stop to it until the issue is resolved. We feel there is no room for not following this protocol," Groah says. "We haven’t had to implement the suspension yet because once we announced it, all the nonbelievers suddenly became believers."