Changes in Universal Protocol to Enhance Safety
In view of the continued incidence, albeit infrequent, of wrong site interventions at BWH, the revised policy for the Universal Protocol assigns responsibility to the operating clinician to perform the safety pause. The operating clinician must lead 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 verbally confirm that the patient, planned procedure, site and side are correct and consistent with relevant 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 them to speak up if they question anything.”
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.
During the safety pause, the team should have with them documentation, such as history and physical, informed consent and radiology imaging, that is needed to verify the right patient, side, site and procedure.
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 the each additional procedure.