Preventing Wrong-patient, Wrong-site, Wrong-procedure Sentinel Events

PUBLISHED: Mar 15, 2018
Relevant to: Ambulatory Care, Clinical Lab, Critical Access Hospitals, Hospitals

The Joint Commission (TJC) recently released updated Sentinel Event statistics for 2017. A total of 805 reported Sentinel Events were reviewed in 2017 and the third most-often reported was wrong-patient, wrong-site, wrong-procedure, with 95 reported events.

TJC’s Universal Protocol was developed to address this serious patient safety issue. The protocol requires organizations to perform a time-out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery.

Components of the Universal Protocol include:

  • Conducting a pre-procedure verification process
  • Marking the procedure site
  • Conducting a “time out” before the procedure

Included with today’s notice are example policies related to the components of the Universal Protocol.

National Patient Safety Awareness Week is a great time to review these policies with key staff members. Taking a small amount of time to raise awareness can go a long way towards preventing wrong-patient, wrong-site, wrong-procedure adverse events.

Want to read the full alert and receive alert emails?

Browse Additional Alerts