National Patient Safety Goals 2009 Sanford USD Medical Center Working together to keep our patients safe…
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National Patient Safety Goals
2009 Sanford USD Medical Center
Working together to keep our patients safe…
Dear Sanford Associates:
The Patient Safety movement is the most important and transforming phenomena that has affected the
healthcare industry in my lifetime. The national focus on patient safety is changing how medicine is
practiced. Medical treatments are more effective, but also more complicated and dangerous today than
they used to be. It is estimated that 40 to 50 patient injuries occur per 100 hospital admissions.
Harm from these injuries reach both inpatients and outpatients (who might be your precious family
member). To prevent harm we need to completely rethink how we approach health care. We must use
what is termed a “human-factors” approach – which looks at how we as human beings function in
complex systems and how such systems can cause harm.
The National Patient Safety Goals (NPSG‟s) are just one response to a national call to action to prevent
patient harm. NPSG‟s are established by The Joint Commission to which we are each held accountable.
The safety goals were formed in response to incidents of actual patient harm and patient deaths. We owe
it to our patients to provide each one with the safest possible care. This booklet outlines goals for safe
care which must be applied to every patient, every time, everywhere. Safe care can only be achieved
with your commitment to work together as a team on behalf of those we serve.
More than simply following a list of things to do however, the safety movement (including the NPSG‟s)
calls medicine back to its reason for existence; a focus on safety.
1. Restores the interest of the patient as the “only” interest to be considered
2. Exposes any agenda that places the patient‟s interest at risk
3. Reminds us that this exclusive focus on the patient has deep roots in the great tradition of
medicine (whatever we do, we must at least “DO NO HARM” – Hippocrates)
4. Demands that the patient‟s interest can only be achieved through total transparency, exposing
harm at every level.
Transparency then is the touchstone of 21st century healthcare delivery (the hero if you will) which
has enemies both external and internal, but mainly internal (that‟s right…me, you and us). These
National Patient Safety Goals will further a culture of transparency. Please make time to learn these
safety goals and personally commit to implementing them for every patient, every time,
everywhere. Thank you for practicing safely!
Wendell W. Hoffman, M.D., F.A.C.P.
Patient Safety Officer
Sanford USD Medical Center
National Patient Safety Goals “What are they?”
“Where did they come from?”
The Joint Commission established the NPSG’s to help
accredited organizations address specific areas of concern in
regards to patient safety.
They are based on ACTUAL patient events; reported from
hospitals across the nation.
“Who is responsible to follow the Safety Goals?”
All hospital employees in areas where safety goals apply
Members of the Medical Staff and other independent
practitioners granted privileges to provide care to patients in
the organization.
*Please contact or email the Sanford Patient Safety Team with any questions, concerns, or
ideas related to Patient Safety at Sanford!
*Additional information on the National Patient Safety Goals may be found by accessing the
Joint Commission website; www.jointcommission.org
Implementing the
SAFETY GOALS for
every patient, every
time, everywhere is
the right thing to do!
IMPROVE THE ACCURACY OF PATIENT IDENTIFICATION
Use at least two patient identifiers (name and birth date) whenever:
Administering medications
Administering blood products
Taking blood samples and other specimens for clinical testing
Delivering dietary trays
Providing any other treatments or procedures
Transporting a patient to another care area
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Steps to check patient identification:
With Medication Administration Record (MAR) open, or test requisition/lab label, diet
order in hand:
1. While looking at the patient ID armband, ask the patient “Please state your name
and date of birth”
2. Compare what the patient says and the ID armband to the requisition in your hand
or MAR on the computer screen at patient bedside.
If patient is unable to state their name and date of birth, compare the name and date of birth on their
armband to the MAR/requisition in your hand.
Any individual removing a patient identification band, blood band, or allergy band will immediately
replace it (on the patient) per Sanford policy.
Remember: Every ID Armband must be reviewed AND initialed by the patient/patient spokesperson
prior to application! (If patient/patient spokesperson is unable to participate; 2 staff members must
verify that the ID band is correct and initial it themselves prior to application). See policy (P-025).
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WHEN DRAWING BLOOD OR OBTAINING A LAB SPECIMEN:
Label all blood tubes/specimens at the PATIENT‟S BEDSIDE to prevent mislabeling errors!
IMPROVE THE EFFECTIVENESS OF COMMUNICATION
TELEPHONE & VERBAL ORDERS
Q: “What is V.O.R.B and T.O.R.B.”?
A: Verbal order READ back & Telephone order READ back!
Hint: In order to READ back an order, you must first have written it down!
For VERBAL or TELEPHONE ORDERS or for reporting of CRITICAL TEST RESULTS via
the telephone: verify the complete order or test result by having the person receiving the order or
test result “read back” the complete order or test result.
VERBAL ORDERS:
If physician is present, ask him/her to write the order directly into the medical record
If a physician is unable to write the order (i.e. during a procedure) then a nurse may
transcribe the order, read it back to the physician, and then document accordingly:
(V.O.R.B. Dr. J Smith/N.Nurse, RN)
VERBAL & TELEPHONE ORDERS:
1. WRITE down what was said
2. READ BACK what you have written to ensure accuracy
„Repeating back‟ an order is not effective. You must WRITE it down and READ it back!
______________________________________________________________________________
“Let’s all use the same language”
S – Situation (What is the situation?)
B – Background (How did we get here?)
A – Assessment (What is the problem?)
R – Recommendation (What do we need to do to fix it? When is that going to happen?)
Did you know??? Communication breakdown accounts for 70% of all Healthcare errors (patient falls,
medication errors, VAP, infections, etc.) Lets all use the same language for our patients
IMPROVE THE EFFECTIVENESS OF COMMUNICATION
CRITICAL TEST RESULTS
1. WRITE DOWN the lab test/result
2. READ BACK what you have written down to ensure accuracy. Give the person
reporting the results your name as requested.
3. Document the critical result on the yellow critical value sticker or follow your
department protocol as defined.
4. Report the critical result to the physician as appropriate per policy.
Refer to the Critical Values Reference Sheet – Administrative SOP C-100
See examples of labs that must be reported to a physician AND documented within 30 minutes:
Refer to policy for additional Nuclear Medicine and Imagining Tests that are included.
Measure, access, and if appropriate, take action to improve the timeliness of reporting, and the
timeliness of receipt by the responsible licensed caregiver.
CRITICAL TEST RESULT (NATIONAL PATIENT SAFETY GOAL 2A)
Write it down, read it back
Critical Values of the following tests are to be called to a MD within 30 minutes of result receipt:
ABGs (Blood Gases * Potassium * Spinal Fluid
Glucose * HgB*/HcT* * Call first instance only
Magnesium (OB patients) * Platelets
Patient Name: _______________________________________________________________________________________
Critical Result:_______________________________________________ Date: _______________ Time: _____________
o Pre-written orders/protocol followed
o MD Notified: _______________________________________ Date: _______________ Time: ______________
Date AND Time Required!
Orders Received? Yes No RN Signature___________________
Place Sticker in Physician Progress Note
IMPROVE THE EFFECTIVENESS OF COMMUNICATION
ABOLISHED ABBREVIATIONS
Standardize a list of abbreviations, acronyms, symbols and dose designations that are not to be
used throughout the organization. The following abbreviations have been shown to contribute to
significant medical errors and must NOT be used.
Abbreviation to be eliminated Approved Alternative
QD Daily
QOD Every other day
U or u Units
IU or iu International Units
MgSO4 Magnesium Sulfate
MS Morphine
MSO4 Morphine
Do not use trailing zeroes, (i.e.4.0) 1 unit (i.e. 4)
Do use a leading zero 0.1 unit
T.I.W. or TIW 3 times weekly
ug Mcg
gr Do not use
H Humulin or Humalog
This list applies to all orders and all medication related documentation when handwritten
or entered as free text into a computer.
If an abolished abbreviation is found: you must contact the prescriber to verify the
meaning of the abbreviation. Then rewrite the clarified order without the abolished
abbreviation.
Refer to administrative SOP A-005: Abbreviation Reference
IMPROVE THE EFFECTIVENESS OF COMMUNICATION
HAND-OFF COMMUNICATION
Implement a standardized approach to “hand-off” communications, including an
opportunity to ask and respond to questions.
Key information about a patient must be exchanged every time the patient is handed over to
another caregiver. Examples include:
Upon admission
Shift Change (Involve the patient in the bedside report when appropriate!)
Temporary transfer of care during lunch, breaks, when primary staff leaves, etc.
Transferring of care between physicians (including transfer of complete responsibility to
another physician and transfer of “on-call” responsibilities).
Transition between departments (Anesthesia to PACU, ER to Critical Care, etc.)
Upon transfer of patient between departments for tests/procedures/therapies
Upon discharge to transitional facilities (i.e. nursing home)
Ticket to Ride
EVERY PATIENT MUST HAVE A TICKET TO RIDE
If a patient is transferring to another department for a test/procedure/therapy and the nurse is
unable to accompany the patient, the patient must have a TICKET TO RIDE!
1. Night shift RN completes a Ticket to Ride and places it in the holder outside the room or inside the
patient chart (department discretion).
2. Transporter is to read the Ticket to Ride (ensure that the RN name & phone number are present) &
inform the patient‟s RN that the patient is leaving the unit. The transporter must have the
opportunity to ask the RN questions if needed.
3. Transporter gives the Ticket to Ride to the next caregiver.
4. Next caregiver reads/reviews the Ticket to Ride prior to test/procedure/therapy.
5. Ticket to Ride is returned with patient to their room following the test/procedure/therapy.
IMPROVE THE SAFETY OF USING MEDICATIONS
LOOK ALIKE/SOUND ALIKE DRUGS Identify and, at a minimum, annually review a list of look-alike/sound-alike
medications used by the organization, and take action to prevent errors involving the
interchange of these medications.
Examples of LOOK-ALIKE/SOUND-ALIKE drugs at Sanford:
Metformin Metronidazole
Hydroxazine Hydralazine
Epinephrine Ephedrine
Zyvox Zosyn
Heparin Hespan
Celebrex Celexa
Novolin Novolog
Be extra vigilant when you are administering one of these medications!
(Notice the TALL MAN Lettering above!)
Be aware of look-alike/sound-alike drugs
Report any identified look-alike/sound-alike medications to the Pharmacy or
Medication Variance Hotline at #3-4567.
Review lists of common look-alike/sound-alike drugs at medication stations and
near the Pyxis machines.
The Medication Safety Subcommittee reviews the list of look-alike/sound-alike
medications used by the organization every year and takes action to prevent errors
involving the interchange of these medications.
HIGH ALERT MEDICATIONS
What is a “High Alert Medication”?
These drugs bear a heightened risk of causing significant patient harm when they are used
in error. Use EXTREME CAUTION when administering these medications!
The following examples of “High Alert Medications” are those that Sanford has
identified and has processes/policies in place to help prevent errors.
Heparin Insulin (IV and SubQ)
Low molecular weight heparin (Lovenox) Propofol
Ketorolac (Toradol) Magnesium Sulfate
Chloral Hydrate Ibutilide (Corvert)
The following medications are common classes of High- Alert Medications
Cardioplegic Solutions
Chemotherapy Agents
Dialysis Solutions
Electrolytes
Epidural or Intrathecal Medications
Inotropic and Vasoactive Medications
Liposomal/Non-Liposomal Medications
Moderate Sedation Agents
Narcotics/Opiates
Neuromuscular Blocking Agents
Radiocontrast Agents
Total Parenteral Nutrition (TPN)
Thrombolytics/Fibrinolytics
This list is not all inclusive and is updated on an annual basis. Please contact our Medication Safety Officer if you have any
questions regarding the medications that have been listed.
MEDICATION LABELING
Label all medications, medication containers (i.e. syringes, medicine cups, basins) or
other solutions on and off the sterile field. Every time a medication or solution is
removed from its original container and placed in another container (syringe, basin
or cup), that container must be labeled.
Medications and solutions both on and off the sterile field are labeled even if there
is only one medication being used.
Labeling occurs when any medication or solution is transferred from the original
packaging to another container.
Medication or solution labels include the medication name, strength, amount (if
not apparent from the container), expiration date when not used within 24 hours,
and expiration time when expiration occurs in less than 24 hours.
All medication or solution labels are verified both verbally and visually by two
qualified individuals whenever the person preparing the medication or solution is
not the person administering it.
No more than one medication or solution is labeled at one time.
Any medications or solutions found unlabeled are immediately discarded.
All original containers from medications or solutions remain available for
reference in the peri-operative/procedural area until the conclusion of the
procedure.
All labeled containers on the sterile field are discarded at the conclusion of the
procedure.
ANTICOAGULATION THERAPY
Reduce the likelihood of [patient] harm associated with the use of anticoagulant therapy.
Notice that Heparin is a Look Alike/Sound Alike drug!
Heparin is also a HIGH ALERT drug – meaning that errors associated with Heparin use
are more likely to have devastating effects for patients!
Safety Strategies:
When questions arise involving the use of anticoagulants, collaborate with the physician, nurse,
and pharmacist to assure safe care is being delivered.
Ensure that the standard heparin infusion orders are used for all patients on intravenous heparin.
Assure patients being started on warfarin (Coumadin) have a baseline INR prior to the first dose.
Assure that programmable pumps are utilized every time intravenous heparin is administered.
Assure that patients being started on enoxaparin, dalteparin, tinzaparin and fondaparinux have a
baseline serum creatinine prior to starting therapy.
Assure patient/family education includes the importance of follow-up monitoring, compliance
issues, dietary restrictions, and potential for adverse drug reactions and interactions.
Document that you have provided education to your patients receiving anticoagulation
therapy in the Education tab in Doc Z – this is a new Joint Commission requirement!
Notify the Program Director for Anticoagulation Services or Medication Safety Officer of
any unsafe practices with anticoagulants so new systems can be designed to eliminate risk.
REDUCE THE RISK OF HEALTH CARE ASSOCIATED INFECTIONS
Reduce the risk of health care-associated infections.
Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene
guidelines.
Hand hygiene is the single most important factor in preventing transmission of
disease causing organisms.
HANDWASHING WITH SOAP AND WATER IS REQUIRED
When hands are visibly dirty or contaminated.
Before eating
After using the restroom
Upon entering and leaving the hospital.
After contact with a patient with C-Difficile
USE WATERLESS ANTISEPTIC OR SOAP AND WATER
Before having direct contact with patients.
After contact with patient’s intact skin, as in taking a pulse, blood pressure, or
lifting a patient.
After contact with body fluids, excretions, mucous membranes, non-intact skin, or wound
dressing if not visibly soiled. If visibly soiled wash first with plain soap and water
followed by waterless antiseptic hand rub.
If moving from a potentially contaminated body site to a clean body site during a
patient’s care.
After contact with contaminated equipment.
After contact with inanimate objects (including medical equipment) in the
immediate vicinity of the patient.
Before donning sterile gloves for procedures requiring sterile technique.
Before inserting indwelling urinary catheters, intravascular catheters or other devices that
do not require a surgical procedure.
To decontaminate hands upon removal of gloves or other personal protective equipment.
The use of gloves does not eliminate the need for hand hygiene.
*When working with patients with Clostridium Difficile, use only soap and water to clean hands.
REDUCE THE RISK OF HEALTH CARE ASSOCIATED INFECTIONS
There is concern for the transmission of multidrug-resistant organisms in acute care hospitals.
This requirement applies to, but is not limited to, epidemiologically important organisms such as:
Methicillin-resistant Staphylococcus aureus (MRSA)
Clostridium difficile (CDI)
Vancomycin-resistant Enterococci (VRE)
Extended-spectrum Beta Lactamase producing organisms
(ESBL).
Preventing transmission depends on these essential strategies:
o Proper Hand Hygiene
o Contact Precautions
o Cleaning/disinfection of patient care equipment
o Cleaning/disinfection of the environment
Reporting Sentinel Events related to health care associated infections:
Goal: Manage sentinel events related to health care-associated infections. A sentinel
event is a case of unanticipated death or major loss of function related to a health
care-associated infection.
Staff is to report the following to Infection Prevention and Control:
Any patient who unexpectedly dies or suffers a major permanent loss of function
associated with a health care-associated infection.
o Unanticipated deaths and injuries that meet the definition of a sentinel event will undergo a root
cause analysis.
o These unanticipated deaths and injuries will undergo a root cause analysis that should answer the
following questions: Why did the patient acquire an infection? Why did the patient die or suffer
permanent loss of function?
REDUCE THE RISK OF HEALTH CARE ASSOCIATED INFECTIONS
GOAL: Prevention of central line-associated bloodstream infections.
Complete the line insertion checklist to reduce bloodstream infection rates!
Follow the Central Line Bundle (ALL COMPONENTS MUST BE PERFORMED):
Central Line Bundle – for every central line placed:
Hand hygiene
Maximal barrier precautions for insertion
o Sterile gown and gloves
o Cap
o Mask
o Full body sterile drape
Chlorhexadine for skin antisepsis
Optimal catheter site selection
o The subclavian vein is the preferred site for non-
tunneled catheters in adults
Daily review of line necessity and removal of nonessential
catheters
Injection ports and catheter hubs are disinfected with alcohol prior to accessing the ports.
Sanford also has Infection Prevention Bundles developed for:
o Ventilator Associated Pneumonia (VAP)
o Catheter Associated Urinary Tract Infections (CAUTI)
Every Infection Prevention Bundle
begins with HAND HYGIENE!
ACCURATELY AND COMPLETELY RECONCILE MEDICATIONS ACROSS THE CONTINUUM OF CARE
What is “Med Rec”??? Med Reconciliation is simply obtaining an accurate & complete home medication list,
comparing that list to medications we are giving the patient in the hospital, and sending the new, complete list of
medications home with the patient on discharge.
1. Obtain a complete & accurate home medication list/history.
At the time the patient enters the hospital or is ADMITTED, a complete list of
medications (including dose, route, frequency, last dose taken and reason for taking) must
be obtained and documented.
o Medications include:
All prescription medications
Sample and Over-The-Counter (OTC) medications
Herbals/Vitamins/Supplements
Often Forgotten: Inhalers/Nebulizers, Patches, Eye/Ear Drops,
Creams/Ointments, Injections, Oxygen, Implanted Pain Pumps
o Sources of Information to obtain medication list from:
Patient/ Family/Caregiver
Patient‟s medication bottles and/or medication list (always verify that the
information on the bottles/list is accurate and up-to-date)
Patient‟s community pharmacy(s)
Patient‟s primary care physician
Past Medical Records
2. Reconcile the home medication list with new orders.
Next, compare the patient‟s home medication list to the medications ordered in the
hospital. If any discrepancies are found (omissions, duplications, wrong
doses/frequencies etc.), notify the provider to review and reconcile the list.
Anytime a patient TRANSFERS within the hospital, a patient‟s medication list must be
communicated to the next provider of service. This communication must be documented.
3. Reconcile medications on discharge.
At DISCHARGE, a complete list of the medications the patient is to take following
discharge is:
o Provided to the patient and/or family AND
o Provided to the next provider of care (receiving facility or provider/physician) and
this communication must be documented.
Some short-stay areas may have a modified medication reconciliation process based on their patient population and
this will be communicated to those specific areas as needed.
REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS
Goal: Implement a fall reduction program including an evaluation of the
effectiveness of the program.
SANFORD’S FALL PREVENTION PROGRAM
Both inpatients and outpatients are screened for fall risk.
Implement “Risk for Falls” DocZ plan of care when necessary.
The fall risk screen is specific to each patient population or department.
A yellow star symbolizes fall risk and a red star identifies a patient who has fallen.
Patients and Families are Educated on fall risk with individualized fall reduction
strategies (bed alarm, wheel chair seat belt, walk only with help).
Link interventions to area of risk. For example, if patient is confused, the interventions
might include moving patient closer to nurses‟ station, hourly rounds, family presence,
and bed alarm.
Universal Fall Prevention is for ALL patients!
Keep environment free of hazards such as wet floors or clutter in the room.
Keep items within reach of patient: call light, telephone, television remote control,
water.
Patients need to be reminded that they may be weaker due to surgery or a procedure
or new medications.
Patients should not walk alone until staff state they are independent.
Patients should wear their glasses, hearing aids, and bring assistive devices from
home such as canes or walkers.
At each handoff: Staff communicates fall risk and safety interventions being used.
Example: “Patient is very weak and a high fall risk with score of 17. Interventions are therapy referral, walk
3X/day, gait belt, TABS monitor when in chair.”
Bones and Bleeds:
o Be on High Alert for patients on blood thinners or anticoagulants (Coumadin,
Heparin, Lovenox, Plavix or Aspirin) beyond therapeutic limits.
o Be on High Alert for patients with Osteoporosis. They have an increased risk for an
injury related to a bone fracture.
Reduce the risk of influenza and pneumococcal disease in institutionalized older adults
GOAL: Develop & implement a protocol for administration and documentation of
the flu vaccine.
1. Assess all adult inpatients for influenza (during flu season) and pneumococcal
immunization status during admission assessment with completion of the Navigator
on DocZ.
2. If patients are eligible to receive either vaccination (and they have not already
received) offer to administer vaccinations during hospitalization.
3. If consent is obtained, administer vaccinations per SMC Medical Staff protocol.
4. If patient refuses, be sure to document the refusal!
“If you could do one thing to help prevent 36,000 deaths and 320,000
hospitalizations every year. . . Would you do it?”
“The Flu Vaccine saves Lives…”
Dr. Wendell W. Hoffman
Encourage patients’ active involvement in their own care as a patient safety strategy
Encourage patients‟ active involvement in their care to help prevent medical errors and
adverse events.
Instruct every patient to: “Please tell us if something doesn’t seem right to you”
Inform patients and families how they may report concerns related to care, treatment,
services, and patient safety issues:
o Tell a member of the patient‟s care team
o Tell the Clinical Care Coordinator
o CONDITION H (3-1234)
Condition H was created to encourage patients’ involvement in their care!
Every patient has the right to activate the Rapid Response Team!
Involve patients in planning their care each shift!
Involve patients in the bedside report when appropriate & ask for their input!
Have all patients watch Dr. Aspaas’ video on the LodgeNet system (video follows Dr. O’Brien’s welcome video). After turning T.V. on, just hit channel up or down button to get to the videos.
This is a great way to advocate for your patients!
The Organization identifies safety risks inherent in its patient population
SUICIDE PREVENTION
Did you know???
Suicide of a care recipient while in a staffed, round the clock care setting has been the #1
most frequently reported type of sentinel event to the Joint Commission!
Yes…Sanford has had patients who have attempted suicide while in our hospital.
The 2 most frequent ways that patients commit/attempt suicide in a hospital:
Elopement and Jumping (Look up!) If a “Code Exit” is called overhead, be
aware that this could indicate a Suicide Attempt and these patients may be
looking for a structure or height where they can jump from.
Strangulation – Be aware of Bed Linens, I.V. Tubing, Call light,
Respiratory/Nebulizer tubing, etc.
What do you need to know???
Patients are screened through the DocZ Navigator questions
Implement “Risk for Suicide” DocZ plan of care as necessary
Patients identified at risk are then screened by a Mental Health Counselor
Staff members can request ANY patient they are concerned about to be screened by a
Mental Health Counselor (this service is free of charge & does not require a MD order).
A Mental Health Counselor can be reached 24/7 by pager #2182
If you identify a patient at risk – DO NOT LEAVE THE PATIENT ALONE! Stay
with the patient until the Mental Health Counselor arrives.
Utilize a Constant Observer & be extra vigilant to ensure the safety of our at risk patients!
Please refer to Suicide Watch policy (S-050) for additional information
Improve recognition and response to changes in a patient’s condition.
Call the Rapid Response Team by dialing #3-1234 anytime…
You are worried about a patient
Acute change in heart rate <40 or >130bpm
Acute change in SBP <90mmHg
Acute change in RR <8 or >28 per min
Acute change in O2 saturation <90% despite O2 and/or O2 >50%
Acute change in level of consciousness
Acute change in Urine Output to <50mL in 4 hours
Significant Bleeding
Signs or symptoms of a Stroke
Signs or Symptoms of an Acute MI
Any staff member may activate the Rapid Response Team!
Please do not hesitate to call if you feel it is necessary – the sooner we act, the better!
Sanford has both an Adult and Pediatric Rapid Response Team!
Patients/Families may activate the Rapid Response Team through Condition H
Universal Protocol Prevent wrong site, wrong procedure, wrong person surgeries
Universal Protocol is required for:
Operating Room
Non-OR settings
Bedside Procedures
Procedural areas
Preoperative Verification
1. Complete the Continuity of Care checklist (Pre-op checklist)
2. VERIFY:
Correct Person
Correct Procedure
Site (as applicable)
Verify this information at the time procedure is scheduled, at the time of admission into
the facility, anytime the patient is transferred to another caregiver, and before the patient
leaves for the procedure.
DO THIS WITH THE PATIENT INVOLVED, AWAKE & AWARE, IF POSSIBLE!!!
Ensure that all necessary documentation is complete & available (H&P, consent,
preoperative labs/diagnostic tests, relevant images, special equipment, etc.)
Utilize the appropriate DocZ flowsheet template – OR surgical/Procedural checklist or OP/IP
Procedure Record.
Universal Protocol
Preoperative Verification
Marking the Site
“Time Out”
Marking the Operative Site
The operative site must be marked prior to the procedure for the following:
o Procedures involving Right/Left distinction (such as Right Nephrectomy)
o Multiple Structures (such as fingers and toes)
o Multiple Levels (such as spinal procedures)
The Proceduralist MUST do the site marking:
o This must occur prior to the patient going to the Operating Room
o The patient must be involved, awake and aware if possible
o R.N. must verify the site marked with the patient, against the consent form,
and procedure schedule whenever possible
Examples of Bedside Procedures requiring Site Marking
Chest Tube Insertion Needle Aspiration
Thoracentesis Biopsy This list is not all inclusive – please refer to policy for additional information.
Exceptions to site marking:
o Single organ cases (i.e. Cesarean section, Cardiac Surgery)
o Interventional Cases when the site is not determined (i.e. Cardiac Catheterization
or Central Line Insertion)
o Teeth – BUT, Indicate the operative tooth/teeth on a dental radiograph/diagram
o Premature Infants – for whom a mark may cause permanent tattoo
Refer to Universal Protocol policy – O-030 for additional information
Why do we mark Operative Sites???
To prevent wrong site surgeries! Yes…this has frequently happened in hospitals across the country!
Marking the operative site with the patient/family involved will help prevent wrong site surgeries!
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“Time Out” Active Communication among ALL members of the team to prevent
wrong site, wrong procedure, wrong person surgeries.
“Time Out”
o Correct patient identity*
o Correct side and site (as applicable)
o Agreement on the procedure to be done
o Correct patient position
o Correct equipment/implants present
*NOTE: When verifying “correct patient identity” at this point, you must recheck the patient ID
Band or ID source for name and date of birth! (See Patient Identification NPSG).
All team members must be present for this!
Active Communication – all members of the procedure team must participate
The “Time Out” must be Fail Safe – the procedure will not start until ALL
questions/concerns are addressed and resolved
Document the “Time Out” on the consent form, in the progress notes, or approved
location per protocol
The “Time Out” is required for Surgery/Procedures AND Bedside procedures!
IF ANY MEMBER OF THE TEAM (OR THE PATIENT) HAS A CONCERN ABOUT
ANY OF THE INFORMATION INCLUDED DURING THE “TIME OUT”, THE
PROCEDURE WILL NOT START UNTIL RESOLUTION IS REACHED AMONG
EVERYONE!
Examples of Procedures Requiring “Time Out”
Bronchoscopy Cardioversion
Biopsy Central Line Insertion
Chest tube Insertion Circumcision
Epidural Thoracentesis
Lumbar Puncture Surgery
PICC Line Insertion Bronchoscopy This list is not all inclusive – please see policy O-030 for additional information
National Patient Safety Goals
2009 Sanford USD Medical Center
Working together to keep our patients safe…
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