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

PUBLISHED: Mar 25, 2019
Relevant to: Ambulatory Care, Critical Access Hospitals, Hospitals, Medical Office

The Joint Commission recently their 2018 Sentinel Event statistics. A total of 801 reported sentinel events were reviewed in 2018; 94 of those reports were related to wrong-patient, wrong-site, wrong-procedure events making it the third most often reported adverse event last year.

In 2003, the Joint Commission made the elimination of wrong site surgeries a National Patient Safety Goal and the next year implemented the requirement that all accredited organizations comply with a Universal Protocol. 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.

The Universal Protocol requires three separate steps:

  1. Preoperative identification of the patient by all members of the surgical team (surgeon, anesthesiologist, nurse,scrub tech)
  2. Marking of the operative site
  3. A final "time out" just prior to the surgery or procedure regardless of where it is being performed

According to the Agency for Healthcare Research and Quality (AHRQ), best practices for incorporating the Universal Protocol into the daily surgical schedule include:

  • Timing: The closer to actual incision time the time out occurs, the less likely a mistake can be made that is irreversible. This does not preclude having additional time outs at other critical points prior to incision, such as just prior to placement of a spinal anesthetic. When multiple surgeons are performing different procedures during the same operative session, multiple time outs should also be occurring.
  • Content: Tailor the content of the time out to the specific procedure—using a combination of checklists and debriefings to maximize the amount of information communicated to team members before, during, and after a procedure. Allow for flexibility and ongoing review so that, as evidence-based practices become known, time outs can be expanded and adjusted.
  • Documentation: All members of the team should perform documentation of the time out: nurses and anesthesiologists documenting its occurrence in their respective records and surgeons documenting in the operative report.

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

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