Part II - 2021 Hospital National Patient Safety Goals Series: Preventing Mistakes in Surgery

In part one of our series over the 2021 Hospital National Patient Safety Goals—a yearly report published by The Joint Commission covering emergent patient safety concerns, performance standards, and measurable outcomes—we covered the challenge of identifying high suicide risk patients.

This next entry addresses Universal Protocol (UP) 01.01.01 of the 2021 NPSG, which covers the necessary safeguards for ensuring surgical procedures are performed “on the correct patient and at the correct place on the patient’s body.”

This second entry provides a brief overview of issues that contribute to surgical identification mistakes, as reported by The Joint Commission. We also offer some recommendations on how hospitals can use electronic perioperative health solutions to equip their surgical departments with customizable tools that help standardize and support the entire surgical care workflow, helping prevent wrong site, wrong side, and wrong patient procedures.

The Issue: Wrong Site, Wrong Side, Wrong Patient

According to The Joint Commission there are an estimated 40 to 60 wrong site surgeries each week in the United States. A collaborative project that included The Joint Commission and hospitals found that there is no single cause to surgical identification mistakes. The project did however, identify areas of the perioperative process where small, compounding errors occur most often, and how they contribute to misidentification. The areas requiring most attention in the report were:

• Scheduling
• Pre-op
• Operating room

In each of these areas the researchers discovered close to 30 main causes, all of which came down to “organizational culture.” Standardized processes must be in place and hardwired into clinician’s workflows to reduce patient medical errors.

Organizational Universal Protocols Are Key to Prevention  

To improve standardization in surgical scheduling, pre-op, and operating room processes, The Joint Commission suggests providers adhere to the following Universal Protocols for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™.

Universal Protocol 1 – Conduct a pre-procedure verification process

For effective prevention of wrong patient, procedure, and site, The Joint Commission suggests facilities have pre-procedure processes in place designed to mitigate surgery risks. These processes will vary depending on procedure, but should include these steps:

• Verification of procedure, patient, and site
• Identification and matching of all items that must be available for procedures like, relevant documentation, diagnostics tests, required products, etc.
• Involving the patient in every step of the preprocedure verification process

Universal Protocol 2 – Mark the procedure site

One of the best ways to protect patients about to undergo surgery is to adhere to a consistent site marking procedure. To add clarity and consistency The Joint Commission states providers should:

• Identify procedures that require marking for incisions or insertions
• Mark site(s) pre-procedure, and when possible, involve the patient
• Assign the marking task to the person most familiar with the procedure
• Adhere to a consistent method of marking as well as the type of mark used
• Create a written alternative process for when patients refuse marking or when other issue arise marking impossible or impractical, e.g. treating internal organs

Universal Protocol 3 – Perform a time-out before procedure

Taking a moment to step back and pause to conduct a final assessment, especially prior to administering anesthesia, allows both team members and patients to place their focus on ensuring accuracy. The Joint Commission suggests that time-outs:

• Occur prior to an invasive procedure or incision
• Occur if two or more procedures are being performed on same patient with different clinicians
• Are standardized by practice, initiated by designated team member, and involve all immediate members of procedure team
• Include time for team members to agree on patient identity, site, and procedure
• Are documented to record all actions completed during time-out

In all listed protocols, The Joint Commission states the consistent use of standardized checklists and processes can significantly decrease surgery misidentification issues.

Improving Process Standardization in the OR

Every step in the patient’s care journey should be supported by a consistent adherence to standardized clinical workflows.

To help hospitals protect their surgery patients from mistakes that can lead to identification errors, we have made standardization a key feature of our surgical platform—MEDHOST Perioperative Experience. Perioperative Experience gives users the capability to add checklists into the platform per a facility’s needs. These helpful features provide more clarity and structure to the perioperative process, ensuring the right procedures are completed on the right patient, on the right location.

To learn more about how MEDHOST Perioperative Experience can help standardize workflows in your hospital with customizable tools, please reach out to us at inquiries@medhost.com or call 1.800.383.6278.