Prevent Wrong Site, Wrong Procedure and Wrong Person Surgery
To prevent wrong site, wrong procedure, wrong person surgeries, BWH has a policy in place for all invasive procedures, including those done at the bedside. This policy also is required by the JCAHO.
In collaboration with the American Medical Association, American College of Surgeons and the American College of Physicians, the JCAHO held a summit in 2003 to determine best practice to prevent this event. The outcome resulted in the JCAHO’s Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.
BWH’s policy of the same name reflects the same requirements of the Universal Protocol comes from the 2003 summit. “BWH recently has appreciated several ‘good catches’ with these safety procedures in place, but we remain at risk when these are not followed routinely,” said Erin Graydon-Baker, MS, RRT, Patient Safety manager.
The hospital policy includes the following.
1. Pre-procedure verification process
- a. Congruence of relevant documents
- b. Availability of required equipment, implants and radiological images
2. Mark the procedure site for invasive procedures that involve laterality, multiple structures or levels even if the procedure is outside of the operating room setting.
- a. Mark must be unambiguous; do not use an “X”
- b. Marking should take place with the involvement of the patient whenever possible
- c. Mark must be visible after the patient is prepped and draped
3. Conduct a Safety Pause just prior to starting the procedure.
- a. Pause is an active process where all members of the team confirm patient, procedure and site, availability of implants and other required equipment and, when necessary, images are available, properly labeled and displayed.
- b. Pause is documented in the medical record on the pre-procedure checklist and procedure note (form #0601173). This documentation attests that the team has actively agreed to these conditions above.