Patient Safety Focus
Changes in Universal Protocol to Enhance Safety
Eliminating wrong site interventions, is the driving force behind a revision in the BWH Universal Protocol. The change in policy makes it the responsibility of the operating clinician to perform the safety pause.
The operating clinician leads the entire operating or procedure team in the pause just prior to the start of the procedure. During the pause, each member of the team will confirm verbally that the patient, planned procedure, site and side are correct and consistent with relevant accompanying documents.
If a team member walks in after the pause has been done, the operating clinician must repeat the pause.
“This is an extremely important change,” said Chief Medical Officer Andy Whittemore, MD. “Although the operating clinician will be held accountable for performing the pause, he or she is also responsible for including every team member in it and encouraging all to speak up with questions.”
The safety pause is not just for OR staff. It also applies to any invasive procedure whether performed in the diagnostic areas or at the bedside.
“As patient advocates, nurses are key participants in the safety pause for all procedures, whether in the operating room or elsewhere in the hospital,” said Kristin Alt Styer, MS, RN, quality program manager for Perioperative Nursing. “Working together with the procedure team and advocating for the patient ensures we are caring for the patient in the safest environment.”
During the safety pause, the team should have with them documentation, such as history and physical, informed consent, radiology imaging, that is needed to verify the right patient, side, site and procedure.
In the OR nursing staff document the safety pause in an electronic OR record, and staff performing bedside procedures should document it on the pre-procedure checklist and progress note. Anesthesiologists performing invasive procedures outside of the operating room, such as epidurals or other regional anesthesia, should record the safety pause on their anesthesia record.
Change to the Universal Protocol
The revised policy includes the following:
The operating clinician (interventionalist, surgical attending, surgical fellow, resident or PA beginning the procedure) will lead the safety pause immediately prior to the incision. He/she will elicit a verbal response from each team member signifying that all relevant documents are present and in congruence at the time of the safety pause. If two or more separate procedures are required on the same patient, the safety pause must be repeated with each new operating surgeon and team immediately prior to the start of each additional procedure.