Quality Risk Management Presentation
Transcript: Problem: Patient Misidentification Causes: Language barrier, holding area nurse mixes up patient's last name, Universal Protocol not followed Root Cause: No regulation in place to ensure policies and procedures are being followed Time out: Verification and Documentation of Surgical Patient and Procedure Prepared By:_________________________ Authorized By:___________________ Endorsed By:_________________________ Effective Date:____________________ Policy: To promote patient safety by providing guidelines for verification of correct site, correct procedure and correct patient for surgical procedures. Procedure: Prior to the start of ANY invasive procedure there will be confirmation of the correct site, the correct procedure and the correct patient. This will be completed in a collaborative manner by the OR team: circulating nurse, scrub tech, anesthesiologist, surgeon. No instrumentation shall be handed to the surgeon prior to the verification procedure. The OR RN will document this on the OR record. If an anesthesiologist needs to perform a treatment (e.g., a peripheral nerve block, prior to the start of the surgery in the operating room), the anesthesiologist and the RN assisting the physician must follow the verification procedure. This includes the confirmation of the correct patient, correct surgery and the correct side, verifying the patient's verbal responses with the ID band and the medical record prior to the administration of the anesthetic block. In the Operating Room: 1. After the patient is draped and before the start of the case, the entire surgical team must do a verbal confirmation. The patient does not have to be awake for this verbal confirmation. 2. The OR RN will initiate the verbal confirmation. This confirmation must include the verification of the correct patient, the correct side/site, the correct procedure, the correct patient position, administration of preoperative antibiotics, and that all the essential equipment and instrumentation is available. 3. The patient will be confirmed using two (2) patient identifiers. Preferred identifiers are the patient name and date of birth. 4. The surgical site marking must be visible at the time of the verbal confirmation. 5. Step 1 and 2 will be documented on the OR nursing record. Source: ASC Durango (Colo). Retrieved from https://www.beckersasc.com/asc-accreditation-and-patient-safety/sample-asc-time-out-policy-and-procedure.html Mrs. Jonesky- Appendicitis, doesn't speak English Samantha Jones- Broken ankle Holding area nurse- mistakes Jonesky for Jones Anesthesiologist- interviews patient Surgeons- perform incomplete time-out Staff members present in procedure- go along with surgeons despite completion of time- out References Use AT LEAST 2 identifiers combination of person specific information such as name, date of birth, social security number, or phone number (Mooney, 2003) Ensure universal identifiers are used throughout organization Universal Protocol implemented by The Joint Commission to help prevent wrong person, wrong procedure, and wrong site surgery in hospitals Three steps of Universal Protocol: Pre-operative/ pre- procedure verification process marking the operative/ procedure site Time- out (final verification) Quality Management- Patient Safety Provide a safe environment, explore the possiblity of failure, and create defenses that will evolve the organization (Youngberg, 2011) Focus on systems and policies rather than specific staff members Communication and teamwork throughout all levels of the organization Regulation- The Joint Commission healthcare organizations must follow standards to obtain and keep accreditation TJC comprised of professionals who work in the field Implementation of standards such as Universal Protocol and using at least 2 patient identifiers. Example of a Time- Out Procedure Recommendations for Improvement: Train Staff on Proper Identification Procedures HCM 520: Quality and Performance Improvement in Healthcare How This could have been Avoided: Completion of Time-Out National Patient Safety Goal in 2007 Mandated healthcare organizations to encourage patient's active involvement in their own care Focus on three areas (AHRQ, 2017) enlisting patients in detecting adverse events empowering patients to ensure safe care emphasizing patient involvement as a means of improving the culture of safety Source: UMC Health System, Lubbock Texas 13.8 percent of United States population speaks a language other than English at home ( Perkins, 1999) Title VI of the Civil Rights Act of 1964 lack of translation services negatively affects cost of care Untrained interpreters not a reliable source Recommendations for Improvement: Translation Services Root- Cause Analysis Meghan Whitebread https://apps.umchealthsystem.com/downloads/ORConsentForms-2009/.Bedside%20Procedures%20Paperwork/Universal%20Protocol%20Checklist%20Rev%20(11)%2008-2016.pdf Root Cause Analysis Diagram Commentary: Important Concepts Agency for Healthcare
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