Ensuring patient safety—AORN's indispensable resources

AORN Journal,  July, 2004  by William J. Duffy

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I have mentioned several times in my messages to you that AORN is determined to be an indispensable resource to you, the members, in practicing your profession. The Board of Directors believes that if AORN membership is going to continue to be of value, AORN needs to find ways to provide members with tools to help them achieve their goal of delivering sale quality patient care.

One area that has been on the minds of health care professionals, as well as members of the public, is wrong site surgery. The Joint Commission on Accreditation of Health Care Organizations (JCAHO) continues to receive reports about incorrect site, procedure, and patient surgery despite numerous attempts to address this issue. The latest effort from JCAHO has been to require health care institutions to comply with its Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery by July 1, 2004. AORN continues to receive comments from members expressing confusion regarding the expectations of JCAHO's Universal Protocol or frustration with the lack of support from physician colleagues in implementing the required steps in the protocol.

CORRECT SITE SURGERY TOOL KIT

The amount of confusion about this topic led AORN to act and take a leadership role. With the help of members of the Presidential Commission on Patient Safety, AORN Board members, and AORN Headquarters staff members, AORN has developed a resource and strategy to help perioperative nurses and health care institutions successfully implement JCAHO's Universal Protocol. To help ensure health care institutions are compliant, AORN worked with JCAHO staff members to produce the Correct Site Surgery Tool Kit, which was distributed to AORN members at the end of May. This tool kit contains a copy of the Universal Protocol, a guideline for implementing the protocol, an educational program with examples on how to implement the protocol, a copy of a JCAHO brochure on preventing errors, and a template for a facility policy.

Although the tool kit was developed by AORN for perioperative nurses, its message to perioperative nurses is strengthened by support from organizations representing other key members of the surgical team. AORN built on the efforts of past President Betty Shultz, RN, CNOR, to establish stronger partnerships with other disciplines in the surgical environment, reached out to its partners, and secured endorsement of the tool kit from the American College of Surgeons (ACS) and the American Society of Anesthesiologists (ASA).

Successful adoption of the Universal Protocol, however, also will require support from health care facility administrators and risk managers. To encourage their support, AORN secured endorsements from the American Hospital Association (AHA), the American Society for Healthcare Risk Management (ASHRM), and the American Association of Ambulatory Surgery Centers. In addition, tool kits were distributed to chief executive officers and risk managers at surgical facilities throughout the United States. In all, more than 55,000 copies of the tool kit have been distributed. I am proud to be part of an Association that has taken such a strong stand and that has reached across perceived boundaries and into the practice environment to help make a difference in patient care.

NATIONAL "TIME OUT" DAY

AORN's strategy also involves getting the message about wrong site surgery, as well as a solution, out to the public. By the time you read this message, AORN and the rest of the country will have celebrated National "Time Out" Day on June 23, 2004.

This day arose from the expectations of the Universal Protocol, which include implementing a "time out" immediately before starting a surgical or invasive procedure. As AORN members reviewed the Association's efforts to help all members of the surgical team eliminate wrong site surgery, they noticed AORN had not done anything for one of the most important players--the patient. By creating National "Time Out" Day, AORN has brought patients into the process to help make them a more active and educated part of the team responsible for ensuring correct surgery.

National "Time Out" Day also is a significant step in AORN's efforts to lead the charge to improve patient safety in the perioperative and invasive procedure environment by demonstrating to the general public that the major organizations in the surgical arena are serious about patient safety and are taking steps to reduce errors. The June 23 date was selected to give members of the public, as well as health care professionals, a timely reminder about the Joint Commission's July 1, 2004, requirement for compliance with the Universal Protocol. AORN was supported in this effort by JCAHO, ACS, ASA, AHA, and ASHRM and received endorsement from a variety of other health care organizations.

A RALLYING CRY

Eliminating wrong site, patient, or procedure surgery should be the rallying cry for every professional in the perioperative environment. The Correct Site Surgery Tool Kit and National "Time Out" Day should help AORN members lead that cry in their institutions. AORN exists to serve its members, and the Association will continue to look for opportunities to make a difference in members' practice environments and in the lives of the surgical patient.