Performance of Correct Statement of the Problem and Impact. - - PDF document

Patient Safety Solutions

Performance of Correct Procedure at Correct Body Site

DR.SAFA A.BUCHEERY General Dental Practitioner

CONTENT

• Statement of the Problem and Impact.
• Associated Issues.
• Suggested Actions.
• Looking Forward.
• Strength of Evidence.
• Applicability.
• Opportunities for Patients and Family Involvement.
• Potential Barriers.
• Risks for Unintended Consequences.
• Conclusions.

Performance of Correct Procedure at Correct Body Site

Statement of the Problem and Impact

Wrong site procedures Contributing factors Impact of the problem:

Marking surgical site Wrong Site Surgery Summit Universal Protocol Patient safety alert on correct site surgery

Associated Issues

The effect of Joint Commission Universal Protocol. Solutions

combination of system organization commitment and modification of individual behaviours to improve the outcomes apply to all areas where interventions are performed

Suggested Actions

Establish the performance of correct surgery at the correct body site as a health-care facility safety priority Ensure that health-care organizations have in place protocols that:

Provide for verification unambiguously mark the operative site with the patient’s involvement performance of “time-out”

Looking Forward

Voluntary reporting of wrong site procedures Incidents reports promote multidisciplinary collaborations and system- based change in all procedure areas

Strength of Evidence

Analyses from the Joint Commission Sentinel Event database and the American Academy of Orthopaedic Surgeons database. Expert consensus

Applicability

Hospitals Ambulatory care facilities Office-based surgical facilities.

Opportunities for Patients and Family Involvement

Involve patients and family

at the preoperative verification. in the surgical site marking process.

The informed consent process

Potential Barriers

Lack of surgeon “agreement” to the standardized approach Failure to recognize risks in procedural settings other than the operating room. Reluctance of staff to question the surgeon when a possible error is identified.

Potential Barriers

Inadequate human resources and knowledge for facilitating processes to be challenged. “Automatic” behavior during the time-out process Insufficient generally accepted research, data, and economic rationale.

Risks for Unintended Consequences

Inconsistent interpretation of an “X” marking to “operate here” versus “do not

• perate here”.

Inconsistency of Universal Protocol procedures among several hospitals within a geographic area. Permanent tattooing of immature skin. Perception of increased workload by staff and decreased efficiencies.

Questions or Comments

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