In part one of our series over the 2021 Hospital National Patient Safety Goals—a yearly report published by The Joint Commission covering emergent patient safety concerns, performance standards, and measurable outcomes—we covered the challenge of identifying high suicide risk patients. Show
This next entry addresses Universal Protocol (UP) 01.01.01 of the 2021 NPSG, which covers the necessary safeguards for ensuring surgical procedures are performed “on the correct patient and at the correct place on the patient’s body.” This second entry provides a brief overview of issues that contribute to surgical identification mistakes, as reported by The Joint Commission. We also offer some recommendations on how hospitals can use electronic perioperative health solutions to equip their surgical departments with customizable tools that help standardize and support the entire surgical care workflow, helping prevent wrong site, wrong side, and wrong patient procedures. The Issue: Wrong Site, Wrong Side, Wrong PatientAccording to The Joint Commission there are an estimated 40 to 60 wrong site surgeries each week in the United States. A collaborative project that included The Joint Commission and hospitals found that there is no single cause to surgical identification mistakes. The project did however, identify areas of the perioperative process where small, compounding errors occur most often, and how they contribute to misidentification. The areas requiring most attention in the report were:
In each of these areas the researchers discovered close to 30 main causes, all of which came down to “organizational culture.” Standardized processes must be in place and hardwired into clinician’s workflows to reduce patient medical errors. Organizational Universal Protocols Are Key to PreventionTo improve standardization in surgical scheduling, pre-op, and operating room processes, The Joint Commission suggests providers adhere to the following Universal Protocols for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™. Universal Protocol 1 – Conduct a pre-procedure verification process For effective prevention of wrong patient, procedure, and site, The Joint Commission suggests facilities have pre-procedure processes in place designed to mitigate surgery risks. These processes will vary depending on procedure, but should include these steps:
Universal Protocol 2 – Mark the procedure site One of the best ways to protect patients about to undergo surgery is to adhere to a consistent site marking procedure. To add clarity and consistency The Joint Commission states providers should:
Universal Protocol 3 – Perform a time-out before procedure Taking a moment to step back and pause to conduct a final assessment, especially prior to administering anesthesia, allows both team members and patients to place their focus on ensuring accuracy. The Joint Commission suggests that time-outs:
In all listed protocols, The Joint Commission states the consistent use of standardized checklists and processes can significantly decrease surgery misidentification issues. Improving Process Standardization in the OREvery step in the patient’s care journey should be supported by a consistent adherence to standardized clinical workflows. To help hospitals protect their surgery patients from mistakes that can lead to identification errors, we have made standardization a key feature of our surgical platform—MEDHOST Perioperative Experience. Perioperative Experience gives users the capability to add checklists into the platform per a facility’s needs. These helpful features provide more clarity and structure to the perioperative process, ensuring the right procedures are completed on the right patient, on the right location. To learn more about how MEDHOST Perioperative Experience can help standardize workflows in your hospital with customizable tools, please reach out to us at or call 1.800.383.6278. What is the goal of the universal protocol?The Universal Protocol provides guidance for health care professionals. It consists of three key steps: conducting a pre-procedure verification process, marking the procedure site, and performing a time-out.
Where is the intention of the universal protocol?In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities.
What is the universal protocol for preventing wrong site surgery called?The Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™ Wrong site, wrong procedure, wrong person surgery can be prevented. This Universal Protocol is intended to achieve that goal.
What is the primary goal of the circulating nurse during preparation of the operating room transferring and positioning the patient and assisting the Anaesthesia team?The circulating nurse manages the operating room and protects the safety and health needs of the patient by monitoring activities of members of the surgical team and checking the conditions in the operating room.
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