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Each member of your surgical team is responsible for ensuring that the correct procedure is performed on the correct patient at the correct site. Here's some advice from the University of Rochester Medical Center in New York for ensuring wrong-site procedures never happen on your watch.
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The surgical department at the University of Rochester Medical Center in New York produced a short video demonstrating the proper pre-op time-out script that all OR teams must follow. Members of URMC's surgical team are featured in the short video, making its lessons more effective. All new hires must watch the video, which also serves as a valuable educational tool for veteran staffers who want or need a refresher on proper time-out and site-verification protocols. Jim Smithers, RN, nurse educator at URMC Ambulatory Surgery Center says the facility's staff made the video using its own resources. Production costs were the staffing hours involved in making the piece (3 hours of shooting time and 5 hours of editing time). Members of the surgical team wrote the script and had starring roles. "We used our own clinical staff as actors to make it more realistic and to impart ownership," says Mr. Smithers. "Our medical director (an orthopedic surgeon) wanted to be in it, to narrate and demonstrate how easy the process is. "Everyone on the production team believes that a visual demonstration of a process leaves less room for interpretation and models the necessary behaviors," he adds. URMC isn't the only facility to produce its own in-house educational video. The Reading Hospital SurgiCenter in Wyomissing, Pa., shot a wrong-site surgery prevention presentation when leadership there noticed inconsistencies in staff compliance with the Universal Protocol's site-marking requirements. Staff members at Reading, after seeing their colleagues use scripted phrases during realistic patient interactions, have a clear understanding of proper patient- and procedure-identification protocols and how they should be applied in practice. — Daniel Cook |
In pre-op
Surgeons should visit patients to make sure the surgical consent is signed and answer any questions they have about the scheduled procedure. As long as the procedure information (location and type, for example) on the surgical schedule and patient consent form match, surgeons must use an indelible marker (so site markings won't fade after prepping solutions are applied) to sign their 2 initials on the correct incision site. In the OR, physicians cut through the initials, which ensures the site marking remains visible even after drapes have been applied.
Have the anesthesia provider, pre-anesthesia nurse and surgical nurse interview and confirm the patient's identity and surgical site. Ask patients to recite their full name, birth date and the procedure they're scheduled to undergo. Confirm the correct surgical site and review the signed consent with the patient. Each team member should identify the intended surgical site, including laterality, and compare it to the surgical schedule, consent and H&P. Clear the patient for the OR only after the surgical site has been cross-checked and the pre-op paperwork has been reviewed (and discrepancies addressed).
In the OR
Ask patients to once again state their name, date of birth and the procedure they're scheduled to undergo. Compare their responses to the patient chart, signed consent and ID wristband. Have the scrub nurse verbally confirm that the marked surgical site matches information on the consent, and that the room's equipment has been set up for the scheduled procedure.
During the time out
Hang posters containing key segments of the time out throughout your facility's clinical areas. Include outlines of the universal time out on the back of your staff's ID badges. Those visual cues serve as valuable educational tools for new hires and welcome reminders for veteran staffers. During time outs, every member of the surgical team must:
- Follow the leader. Stop what you're doing, cease unnecessary conversations, turn off the stereo and focus on the person leading the pre-op pause. The surgeon should initiate the time out by confirming that the nurses have identified the patient's name and date of birth against the identification armband. He then states the patient's name, date of birth, the procedure he's about to perform, the position the patient is in and the correct location of the surgical site. He announces that his initials are visible on the correct site and asks members of the surgical team to verbally verify, while pointing to the site, that the markings can be seen. The entire team must then verbally agree that it is safe to proceed with the case. Each member of the surgical team is also empowered to issue a "hard stop" — stopping the procedure at any time if the team is not in full agreement about an action or site- and patient-identifier.
- Make it matter. Don't passively recite the all-too-familiar language of pre-procedure pauses. Instead, develop scripted safeguards and assign specific roles to surgical team members. Each surgical tech, nurse, surgeon and anesthesia provider should be an active participant, focusing on the necessary steps to confirm the correct patient, procedure and site. Have anesthesia providers check that the patient's name and date of birth match the ID wristband. Ask the scrub tech to point to the correct surgical site. Charge the circulator with announcing that the surgeon and patient have signed the consent form. Ask surgeons to point to the initials he marked on the patient. Instead of confirming that the correct site has been signed with a simple "yes" or "no" response, announce that the surgeon has marked the correct site and point to his initials.
Remember, active participants in the timeout process are consciously involved in confirming the correct patient, procedure and site. They're also more inclined to speak up when disagreements arise concerning the confirmation of any of those safeguards.
Customized for success
URMC's time out and site-marking protocols are based on the Joint Commission's National Patient Safety Goals, the World Health Organization's Safe Surgery Saves Lives Campaign and AORN's Perioperative Standards and Recommended Practices. But they're effective because the surgical and regional block teams made them their own, tailoring the requirements based on input from a dedicated team of staffers. The culture has changed within URMC's procedure rooms and ORs, making effective time outs and site markings routine standards.
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