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.
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.
According 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.
To 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.
Every 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 firstname.lastname@example.org or call 1.800.383.6278.