Keeping patients safe—procedure and site verification and preprocedure pause

AORN Journal, April, 2004 by Barbara Rusynko, Judith Perry-Ewald

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has a new emphasis by on national patient safety goals. (1) This prompted Inova Health System (IHS), Falls Church, Va, a multifacility health care organization with five hospitals that performed more than 66,000 surgical procedures in 2002, to consider a standardized, system-wide policy for procedure verification and a preprocedure pause. Many of the eight ORs at IHS previously had instituted processes that included marking surgical sites, a preprocedure pause, and other safety measures to prevent surgical errors related to the wrong patient, wrong procedure, or wrong side.

The challenge of implementing a system-wide policy for procedure site verification and a preprocedure pause is that this also affects the care of patients beyond the doors of the OR suite. The assistant vice president for performance improvement and outcomes realized the task would call for cooperation and teamwork from numerous patient care areas within the health care system. The journey to adopt and implement one policy for all departments at five hospitals was framed as a patient safety summit. The concept behind the summit was to hold a single meeting with all of the stakeholders to reach consensus for a procedure site verification policy that then would be piloted for three months. At the end of the pilot program, feedback would be used to finalize the policy and create an implementation plan during a second summit.

Representation for the summit from each IHS hospital included quality specialists, risk managers, physicians, clinical nurse executives, educators, and department directors from a variety of clinical departments, including ORs, intensive care units, emergency departments, labor and delivery, catherization laboratories, endoscopy suites, interventional radiology, and units where a variety of invasive procedures are performed. In preparation for the first summit, all team members were sent materials, including literature on procedure site verification and a draft of a procedure site verification policy that combined best practices from policies already in place within the system. (2)

First Summit Meeting

On the day of the summit, each hospital in the system had representatives present. The meeting was facilitated by the performance improvement and risk management department. Discussion during the first summit focused on several points.

* Should departments, such as endoscopy and interventional radiology, have a separate policy because things are done differently outside the OR? After a variety of opinions were presented, the consensus was to have one policy for all areas to reduce the risk of error. The literature shows that using different policies for similar tasks increases the risk for error because confusion that can result from having different policies could lead to error.

* Should some procedures be eliminated from compliance with the policy because it is unreasonable to mark certain sites? Thought-provoking dialogue on this issue ensued regarding what can and cannot be marked. For instance, a patient cannot mark his or her own back effectively. An anatomical diagram was suggested and supported as an alternative to marking on a patient's actual body if that is technically difficult or impractical. After the diagram was tested in the pilot, it became evident that the map was too small to be useful; therefore, it was eliminated from the final process, and a comment section for written clarification was added.

* To which type of procedures should the policy apply? A discussion about this resulted in thoughts about how to delineate when procedure site verification should be used. For example, should caregivers use it when they insert an indwelling urinary catheter or a chest tube or perform a closed reduction of a shoulder in the emergency room? The group agreed that the policy would be used for procedures that require informed consent.

* Who should initiate the procedure pause before the start of the procedure? A nurse or an anesthesia care provider is not always present for every type of invasive procedure. A technician may be present instead of a nurse, depending on the type of procedure. The summit team agreed that the RN or technician assisting with the procedure would call for the pause.

At the close of the first summit meeting, general concepts were agreed on so the policy could move to the pilot phase. The pilot would include implementing a form called a boarding pass to document the verification of required preprocedure actions, such as the history and physical, informed consent, site marking, and the preprocedure pause. The anatomical map was part of this document during the pilot and later was replaced by a comment section as mentioned previously.

Next Steps

Areas of responsibility were assigned to a number of individuals at each hospital. These responsibilities included communicating with all groups that needed to be made aware of this practice change. Groups included physicians' medical executive committees, surgical suite committees, physician specialty sections, and all clinical units involved with the care of patients in which this policy would apply. An education plan was executed for the implementation, and the pilot was initiated.