Patient Safety - PowerPoint PPT Presentation

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Patient Safety

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Practice model on marking the correct surgery/procedure site ... all members of the OR team can 'interrupt' for verification check of proper site. ... – PowerPoint PPT presentation

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Title: Patient Safety


1
building
THE FOUNDATIONS
for patient SAFETY
collaboration
communication
education
Marking the Correct Surgery/Procedure Site
2
Overview of Presentation
  • Patient safety initiative
  • Practice model on marking the correct
    surgery/procedure site
  • JCAHO focus on sentinel events- focus on
    wrong-site surgery
  • Florida legislation- focus on wrong-site surgery

3
Patient Safety Initiative
  • The Patient Safety Steering Committee is an
    interdisciplinary collaborative spearheaded by
    the FHA and includes 14 organizations. The
    Committee has taken a leadership role in
    providing guidance, direction and priorities
    related to initiatives related to patient safety,
    focusing on medical error.

4
Practice Model Guidelines
  • The Patient Safety Steering Committee has
    developed four practice model guidelines in
    medication safety and one on marking the correct
    surgery/procedure site.
  • These guidelines do not constitute the standard
    of care and are not intended to be the only
    practice methods for use.

Building Foundations
5
Practice Model Guidelines
  • Developed so all hospitals would be able to
    implement them regardless of their size, level of
    automation, and location.
  • Intended to be used by the health care team in a
    collaborative approach so that all aspects and
    caregivers are involved in the improvement
    process.
  • These guidelines should be tailored to each
    organizations unique structure, policies, and
    resources so that the best results can be
    achieved.
  • They are based on current literature and research
    related to the particular practice.

6
Marking the Correct Surgery/Procedure
SiteSurgeons Role
  • The surgeon must be
  • involved in the consent process
  • note the correct site in his documentation
  • consider having him co-sign the site, if
    possible.

7
Marking the Correct Surgery/Procedure
SitePatients Role
  • Require the patient and/or patients family to be
    an active participant in identifying the
    appropriate surgical/procedure site.

8
Marking the Correct Surgery/Procedure
SiteMarking the Site
  • Clearly mark either the correct side or the
    incorrect side with YES or NO.
  • A clearly marked site should be used with
    indelible marking pen (e.g. Do not cut here or
    Do cut here).
  • The use of an X is misleading as in does X mark
    the spot or does X indicate this is not the right
    site.
  • Be sure patient is not allergic/sensitive to
    marking pen.

9
Marking the Correct Surgery/Procedure
SiteRecords/Documentation
  • Have all relevant patient information available
    before surgery/procedure and ensure that all
    sources match with the same site. (Medical
    record, Xrays, tests, etc.)
  • Patients chart, OR schedule, and consent form
    must all be in agreement and reviewed in Pre-op
    holding with patient/patients family.

10
Marking the Correct Surgery/Procedure
SiteRecords/Documentation
  • Consider the use of a body diagram in
    documentation, clearly marking the correct
    surgical/procedure site.

Surgery Site Verification
11
Marking the Correct Surgery/Procedure
SiteVerification
  • Require oral verification of the correct site in
    the OR/Procedure Room by ALL members of the team
    do not rely only on surgeon.
  • Ensure that all members of the OR team can
    interrupt for verification check of proper site.

12
Marking the Correct Surgery/Procedure
SiteVerification
  • In operating room, prior to prepping and draping,
    the anesthetist/anesthesiologist, surgeon,
    circulator and charge nurse re-verify proper
    site.
  • Use a verification checklist.

13
Marking the Correct Surgery/Procedure SiteMonitor
  • Have a monitoring system for verification
    procedures.

Surgery Site Verification
14
Marking the Correct Surgery/Procedure SiteJCAHO
Focus
  • Organizations must now respond to suggestions in
    Sentinel Event Alerts within 45 days of
    publication.
  • Organizations must consider suggestions as
    appropriate to their services and implement the
    suggestions or reasonable alternatives or provide
    a reasonable explanation for not implementing
    relevant changes.
  • Sentinel Event Alert (8/28/98) addressed Wrong
    Site Surgery

15
Marking the Correct Surgery/Procedure SiteJCAHO
Focus
  • Sentinel Event Alerts are now scored during
    surveys.
  • Surveyor will assess familiarity with and use of
    Sentinel Event Alert information.
  • Failure to comply will result in a type I
    recommendation.

16
Marking the Correct Surgery/Procedure SiteJCAHO
Focus
The intent of standard PI.4.2 will be changed to
read External sources are as up-to-date as
possible and include recent scientific, clinical,
and management literature, including relevant
Sentinel Event Alerts . . .."

17
Marking the Correct Surgery/Procedure Site2001
Legislation (CS/SB 1558)
  • Requires hospitals and ambulatory surgery
    centers to implement and continually evaluate
    appropriate procedures, protocols and systems to
    accurately identify patients, planned procedures,
    and the correct surgery site in order to minimize
    the performance of wrong-site surgery, surgery on
    the wrong patient, wrong procedures or a
    procedure unrelated to the patients medical
    condition.

18
Marking the Correct Surgery/Procedure Site2001
Legislation (CS/SB 1558)
  • Designates an adverse incident (wrong patient,
    wrong-site procedure, wrong procedure,
    unauthorized procedure or medically unnecessary
    procedure) as grounds for disciplinary action
    (Chapter 456). Patient preparation is
    specifically included in the scope of services
    subject to the provision.

19
Marking the Correct Surgery/Procedure Site2001
Legislation (CS/SB 1558)
  • Designates leaving a foreign body in a patient,
    regardless of the intent of the practitioner, as
    a violation of the standard of care, not in the
    best interests of the patient and grounds for a
    disciplinary action (Chapter 456).

20
Key Learnings
  • Wrong-site surgery still occurs despite awareness
    from health care organizations
  • JCAHO has implemented standards for hospitals to
    implement suggestions on wrong-site surgery
    (Sentinel Event Alert)
  • The 2001 Florida legislature enacted new laws and
    disciplines related to wrong-site surgery
  • Models can promote safe practices

21
References/Resources
  • Florida Patient Safety Steering Committee
    Practice Model for Marking the Correct
    Surgery/Procedure Site (www.fha.org)
  • VHA Surgical Site Verification- The 7 Absolutes
  • FHA Helpful Hints on Preventing Surgery on the
    Wrong Site (www.fha.org)
  • JCAHO Sentinel Event Alert-August 28, 1998
    Lessons Learned Wrong Site Surgery
    (www.jcaho.org)

22
References/Resources
  • American Academy of Orthopaedic Surgeons
    position statement
  • Association of Operating Room Nurses
    (www.aorn.org)
  • QRC Advisor 15(9), 6-8 Prevention of wrong-site
    surgery
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