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Best Practices for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery

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Best Practices for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery

According to the Joint Commission, wrong site, wrong procedure and wrong person surgery is a frequently reported sentinel event through 2Q 2016.  As every health care organization knows, wrong-patient, wrong-site, wrong procedure events are devastating for both the patient and the staff involved.

TJC’s root cause analysis report finds that contributing factors to wrong-patient, wrong-site, wrong procedure incidents include:

  • A failure of leadership factors such as planning, organizational culture, resource allocation, complaint resolution, use of clinical practice guidelines, inadequate and/or lack of compliance policies and procedures
  • A failure of human factors such as staffing levels, staffing skill mix, appropriate staff orientation and in-service education, staff supervision (including resident supervision)
  • A failure of communication among physician and staff, including oral, written and electronic

The Joint Commission’s Universal Protocol is designed to address wrong site, wrong procedure and wrong person surgery and other procedures.  It is comprised of three components:

  • Pre-procedure verification: Confirming the correct procedure, correct patient and correct site. Whenever possible the patient should be included in this step. Standardized procedure lists can be used to ensure items necessary for the procedure are readily available.  At a minimum there should be a history and physical, a signed consent form that matches the procedure being performed to the patient.
  • Site marking: Mark the site where the procedure is to be performed. When it is technically or anatomically impossible or impractical to mark the site (as in this case with a mucosal surface) there should be a written process for ensuring the correct site it operated on.
  • Time out: A time-out should be conducted immediately before starting any invasive procedure or making an incision:
    • A designated member of the team should start the time-out
    • Time-outs should be standardized, involves the individual performing the procedure, any anesthesia providers, circulating nurse, operating room technician and other active participants who will be participating in the procedure from the beginning
    • The completion of the time-out should be documented
    • Note: The procedure should not be started until all questions or concerns are resolved.

Additional considerations:

  • Site marking must be done for any procedure that involves laterality, multiple structures or levels, even if the procedure takes place outside of an OR.
  • Verification, site marking and “time out” procedures should be as consistent as possible throughout the organization.
  • When the individual doing the procedure is in continuous attendance with the patient, from the time of decision to do the procedure and consent to the performing of the procedure; the requirement for a “time out” final verification still applies; the site does not need to be marked.

Sign up for a free trial of StayAlert! and access 7 customizable policy and procedure templates to assist your organization with the prevention of wrong-patient, wrong-site, wrong procedure incidents.



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