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The protocol’s new requirements ensure that patient verification is no longer just a one-time procedure. For example, the verification procedure is first done at the time surgery is scheduled, and again during admission. In the holding area where patients are still awake and aware, nurses and staff once again verify the correct patient, procedure, and surgical site. The procedure also is repeated any time the responsibility for care of the patient is transferred to another caregiver. “We tell patients that we will ask them identifying questions multiple times for their own safety,” says Elizabeth Wein, RN, MPS, CNOR, CNAA, director of perioperative services at Solaris Health System’s JFK Medical Center in Edison, N.Y., and Muhlenberg Regional Medical Center in Plainfield, N.J.

Now, the patient verification process also includes patient involvement. JCAHO states that patients have a role in making their surgical procedure safe by becoming “active, involved, and informed members of their health care team.”

“We ask alert patients to initial their surgical sites to help make surgery safer,” says Sandy Godcharles, RN, preop charge nurse at University of Colorado Hospital in Denver. At some facilities, the operating surgeon initials the site but involves patients when possible.

Although the protocol doesn’t specify the type of mark, JCAHO states that the surgical site marking method [chosen by the facility] must be consistent throughout the organization. Rather than an “X” at the spot, the mark must be unambiguous — the patient’s or surgeon’s initials, the word “YES,” or a line representing the proposed incision. The marker used must be permanent and visible after the patient is prepped and draped. Hospitals must determine a policy for patients who refuse site marking.

“Time-out” is another protocol initiative. Immediately before surgery begins, the surgical team takes a time-out. For a few seconds, the entire operative team comes together for a type of “surgical mindfulness” — awareness in that moment of what they are preparing to do. During the time-out, the surgical team checks that all members agree on the identity of the patient, procedure, surgical site, correct patient position, and the availability of correct implants and any special equipment or requirements. JCAHO suggests that this be documented with the type and amount of documentation determined by the facility.

“The idea to stop and think preoperatively isn’t new,” says Patti Sligar, RN, nurse manager of the main OR at Metropolitan Methodist Hospital in San Antonio. “The time-out formalizes it and takes it to the next level.” During time-out at Metropolitan Methodist, the circulating nurse docu ments the team’s confirmation of verification on a computerized checklist. For additional safety, the perioperative documentation process cannot continue unless every prompt on the site verification screen is answered.

The practical side

The protocol was needed, but some facilities found it difficult to put the new rules in place. “Though facilities had surgical protocols in place, several were struggling. Some had varying interpretations of the universal protocol, and many had questions,” says Pauline Robitaille, RN, MSN, CNOR, chief nursing officer of AORN and vice president for professional services. To help health care providers implement the universal protocol, AORN developed a Correct Site Surgery Tool Kit.

AORN distributed 55,000 tool kits to members, hospital risk managers, and CEOs of hospitals and ambulatory care facilities. The kit provides a variety of resources to educate health care providers about the universal protocol. It supplies a CD-ROM featuring best practice techniques, a copy of the universal protocol with a pocket reference card, a list of frequently asked questions about the universal protocol with answers, and a sample policy template that facilities can adapt and customize.

“Rather than a culture of blame, we should applaud positive behaviors that can reduce the risk of error,” Seifert says. “Instead of a ‘near miss,’ we should say, ‘good catch.’ This is an important distinction.” Rather than preventing errors, the positive spin is patient safety. “Patients expect and deserve safety,” Wein says. “If we can’t provide the correct procedure in a safe environment, why come to the hospital?”

Lorraine Steefel, RN, MSN, CTN, is a senior staff writer for Nursing Spectrum, which publishes NurseWeek.

To view the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery, visit the JCAHOwebsite www.jcaho.org.

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