Accreditation

Mark surgical sites consistently

Accreditation Connection, April 26, 2004

Although organizations have until July 1 to comply with the JCAHO's Universal Protocol for Preventing Wrong-Site, Wrong-Procedure, Wrong-Person Surgery (tm), facilities should work on changing safety culture as soon as possible to make the transition smoother, experts say.

The JCAHO has already made eliminating wrong-site surgery National Patient Safety Goal #4, but the accreditor continues to receive sentinel event reports on a regular basis from facilities that have had a wrong-site, wrong-patient, or wrong-procedure surgery, says Susan Goodwin, RN, MS, CNS, CPAN, the compliance coordinator for the Surgery Center of Edmond, OK. The sentinel event reports consistently identify poor communication among staff and patients and inconsistent site-marking procedures as the main reasons for the errors, says Goodwin.

The JCAHO's universal protocol requires facilities to establish a consistent preoperative verification process and for staff to take a time-out immediately before starting a surgery to make sure everything is correct, says Goodwin. Complying with the protocol will require a culture change for many organizations, says Jan Allison, RN, a compliance coordinator at Physicians Surgical Center in Norman, OK.

Improve consistency

In 2003, JCAHO surveyors found that 35% of organizations were not consistently marking surgical sites, says Della Lin, MD, director of continuing medical education at the Queen's Medical Center in Honolulu. In addition, organizations noticed when they incorporated Patient Safety Goal #4 into their procedures there was little consistency between different facilities for how to mark surgical sites. This causes problems in the ambulatory setting, since many surgeons, nurses, and anesthesiologists work in numerous centers, says Allison. Some centers marked yes on the correct site, other facilities had the patient mark the correct surgical site, and many organizations would mark both the correct and incorrect site, says Allison.

When the universal protocol becomes a requirement in July, it will help eliminate variability between different facilities, says Lin.

The universal protocol was created to help reduce inconsistencies and to help staff communicate with the surgical team and the patient. The protocol requires the following:


Only mark the operating site


Always mark the surgical site if there is a left and right distinction, multiple structures such as fingers or toes, or multiple levels such as spinal surgeries


Mark the general area of the body for spinal procedures and the specific site on the patient's x-ray


Don't mark for caesarean sections, laparoscopic procedures, cardiac catheterization, or intravenous insertions

What about for surgeries involving ears or genitals? Mark the external ear if you need to operate on one of the inner ear canals, and mark the correct site for genitalia on a diagram in the patient's chart, recommends Allison.

TIP: Organizations should develop policies for specific surgical situations and follow the policies consistently. For example, if a surgeon plans to operate on a bilateral hernia and will work on two different sides, consider marking the sides number one and number two.

Make marks as close to the site of incision as possible, and ensure that they are visible after the patient has been prepped and draped for the procedure, says Allison. Each organization must decide what mark it will use to label surgical sites, but staff should remember that an X is often mistaken as either the correct or incorrect site, she says.

Don't lose the site-marking

Stick-on labels are not acceptable ways to mark surgical sites, says Allison. They can easily fall off or move accidentally. Also, avoid marking the site with anything that could wash off as a result of skin preparations prior to surgery, says Allison.

For example, a nine-year-old boy decided to play a practical joke before his carpal tunnel procedure. The correct site was marked with a water-soluble pen and placed near the boy. The boy licked off the marking and made a new mark on the opposite arm, says Allison. A nurse discovered what he did when checking the boy's medical record prior to the start of the procedure.

TIP: Involving patients doesn't mean they necessarily have to physically mark the sites, says Allison. Instead, consider making patients verbally state the correct site, rather than just repeating the site you tell them, says Allison.

 

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