• E-mail
• Print
• RSS

How one hospital guards against the Universal Protocol--wrong-site surgical errors

Accreditation Connection, July 2, 2004

The policy to protect against wrong-site surgical errors at CGH Medical Center in Sterling, IL, includes a series of double-checks to ensure that all staff verify the operable site against documentation in the patient's medical record.

For example, patients aren't supposed to leave the preop holding area unless their site has been marked and confirmed by the preop holding nurse. But if this important step somehow slips through the cracks, the check still happens because the surgical director also reviews a preop checklist. It includes all the steps that staff must take before the procedure can begin, which includes marking the site and verifying the mark against the physician's orders, office notes, and signed informed consent form.

"Nursing must go through this line by line. It reminds them, again, of what to do," says Kristie Geil, RN, MSN, CPHQ, manager of quality and medical staff services.

The following are specific elements of the hospital's three-page policy:

1. Verification of the patient and the procedure: Immediately before performing the surgery, a licensed surgical staff member must confirm the patient's identity by matching the name and birth date listed on the patient's armband with either

- verbal confirmation from the patient or the patient's guardian
- information in the physician's orders, office notes, or progress notes
- the patient's history documentation
- the patient's signed informed consent
- the surgery schedule
- the patient's diagnostic images

The surgeon verifies the procedure by checking information in the patient's medical history, the progress notes, or the physician's office notes against the informed-consent form that the patient or guardian has already signed.

2. Zero-tolerance abbreviation policy: The physician may not use any abbreviations when obtaining informed consent from the patient. This avoids confusion with certain abbreviations that have ambiguous interpretations.

3. Marking the site: The hospital requires either the patient or a family member to mark the surgical site (unless it is "impossible or technically impractical," such as for a tonsillectomy or hemorrhoidectomy).

Immediately before surgery, while the patient is still coherent, a licensed member of the surgical team must ask the patient to verify that the site has been marked correctly. He or she must also confirm this verification with information in the patient's medical record, and then document in the patient's chart that the double-check confirmation was made.

Finally, the surgeon must call a "time out" immediately before beginning the procedure to confirm with all team members that they have the correct patient, procedure, and surgical site.

If there are any discrepancies, any member of the surgical team is authorized to stop the procedure. If that occurs, the surgeon must confirm the surgical site and procedure by reviewing the patient's chart, x-ray films, and the physician's office notes. If a discrepancy remains, the procedure must be cancelled until verification is possible.

• E-mail to a Colleague
• Print
• RSS
• Archive