The 3 R's
Hospitals take time out to verify the right site, right procedure, and right patient as part of multidisciplinary safety campaigns

By Karla A. Knight, RN, MSN
August 2, 2004

If you were in the OR June 23, you probably had an opportunity to take a “time-out.” Not the one imposed on small children for inappropriate behavior, but the kind designed to ensure that the right patient is getting the right surgery.

National Time Out Day was sponsored by the Association of periOperative Registered Nurses and several others of the more than 40 professional health care associations and organizations that support JCAHO’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Patient Surgery.

As of July 1, all surgical teams in JCAHO-accredited hospitals, ambulatory care, and office-based surgery facilities are required to take a moment before the first cut and make sure that the team is operating on the correct patient and doing the correct surgery on the correct body part. Preoperative verification, marking of the site, and the time-out, which immediately precedes the first incision, are required elements of the Universal Protocol.

The protocol also is intended for any invasive procedure, whether it’s in a surgical suite, emergency department, or radiology, said Linda Groah, RN, MSN, FAAN, chief operating officer and nurse executive for Kaiser Permanente San Francisco Medical Center and member of JCAHO’s Professional and Technical Advisory Committee. “Wrong site surgery is basically unforgivable. There’s no going back,” she said. “The hope is that the Universal Protocol will prevent these surgeries from happening.”

The protocol reflects the fourth of seven patient safety goals established by JCAHO and is intended to prevent the more than 100,000 deaths that occur annually in the health care system because of human error. “This protocol fits into the goal of making any hospitalization or health care experience for patients less traumatic and less dangerous,” Groah said.

Groah, as a past president of AORN and a nurse for 40 years, is aware of the importance of multidisciplinary approaches to patient safety. She also has encountered some resistance from surgeons about implementing the protocol because it’s feared that it will take too much time.

“That’s not true,” Groah said. “The time-out only needs to take 30 seconds to verify the patient, the site, the procedure, the position of the patient, imaging studies, the medical record, and any special equipment or implants.” She recognizes that people are struggling with the protocol, but because it requires that everyone take time to focus on the patient, she also believes that communication among the multidisciplinary team will be improved.

Time for action

Although the time-out procedure requires some patience from the surgical team, the theme of the recent National Patient Safety Foundation Congress — “Let’s Get On with It!” — conveys the impatience that many national health care leaders and clinicians feel about the overall state of patient safety. May 3-7, the sixth Annual Congress in Boston was attended by 1,300 nurses, physicians, risk managers, policy-makers, engineers, and others who heard about policies, programs, and research that bring about better practices to safeguard patients.

Connie Crowley Ganser, RN, MS, who attended the congress, said that the theme reflected her own impatience. “Pretty universally, people have recognized that patient safety is important,” she said. “There is, however, a sense of challenge from where we are now to where health care is a more highly resilient industry.”

Ganser is founder and principal of a consulting practice, Health Care Strategies for Patient Safety and Quality. She recently started the business after working for many years in risk management, quality, and patient safety. “One of the biggest challenges is getting beyond the concept of regulation and compliance, and really driving patient safety agendas that are unique and specific to individual organizations,” she said.

One organization that has been able to do this, Ganser said, is Virginia Mason Medical Center in Seattle.

The hospital sent Robert Caplan, MD, and Cathie Furman, RN, MHA, vice president of quality and compliance, to the congress, where they led a workshop, “Stopping the Line for Safety: How to Get Zero Defects in Health Care Quality,” which described a proactive effort by the medical center to reduce patient errors. Anyone identifying a patient safety concern that might cause significant harm notifies a patient safety team that is on-call around the clock. The team, including the executive accountable for the reported area, would immediately evaluate the “patient safety alert” and try to prevent the error.

“It’s unique that we make a patient safety alert a top priority, but that is critical to the success of this particular program,” said Charleen Tachibana, RN, MN, chief nursing officer at Virginia Mason. “It’s also a strong message to staff that this work is important.”

“It’s critical that the team have the authority and the accountability to ‘stop the line’ — that is, remove whatever is potentially harmful to the patient whether it’s a product, procedure, or another person,” Furman said. In one instance, an elevator was removed from service because the nursing staff was concerned that it kept breaking down — with unstable patients inside.

Reporting of patient safety alerts is up 35%, but that’s not enough, Furman and Tachibana say. They want to see reports increase to 800 per year so that potentially harmful situations are detected earlier in the process. “We want nurses and other staff to increase their reporting,” Furman said. “We want them to come forward and tell us what is putting them in jeopardy due to process breakdown. We’re starting to fix the things [nurses] deal with every day that have been frustrating to them for years.”

Communication is key

As director of risk management and quality assessment for Beta Healthcare Group in Alamo, Calif., Elaine Bierman, RN, BS, knows the value of good communication. A nurse for 34 years, 14 of them in risk management, she understands how patient safety can be compromised when communication fails. Bierman also attended the congress and was interested in a presentation on the breakdown in communication among the patient, the caregiver, and the hospital. “Patients, Family, Clinician Partnerships that Change Culture: The MITSS Story” was presented by Frederick van Pelt, MD, and Linda Kenney, a patient who was undergoing ankle surgery when van Pelt inadvertently injected nerve block anesthetic into her bloodstream, causing cardiac arrest.

Kenney recovered, but said at first she was denied access to anyone who might help her understand what went wrong. She and van Pelt used their experiences to help patients like Kenney by founding Medically Induced Trauma Support Services (www.mitss.org).

“In addition to providing direct emotional support to patients and families, the mission of MITSS is to serve as an advocate to increase awareness of the emotional impact that these events have on all involved and to promote the development of coordinated follow-up support,” Kenney said. “Patients, families, and clinicians all suffer when adverse events occur and they need to be taken care of.”

Bierman said that Kenney and van Pelt conveyed the importance of disclosure and communication when an adverse event or unanticipated outcome occurs. “We have yet to know if this type of disclosure reduces the incidence of malpractice claims,” she said, it does go a long way toward helping all parties to the event understand what each is going through.”

Bierman thinks that a congress like this highlights practical ways to deal with patient safety. “This kind of conference helps all of us create a safer work environment,” she said. “It’s also motivating to hear speakers who are so committed to providing safe care and good care to patients.”

What was particularly exciting about this congress, Ganser said, was the number of organizations and multidisciplinary teams that came forward to share their own knowledge and best practices. “Learning and sharing have become hallmarks of the patient safety movement,” she said.

Please go to the next page to see the
2004 National Patient Safety Goals

2004 National Patient Safety Goals

1. Improve the accuracy of patient identification.

a. Use at least two patient identifiers (neither to be the patient’s room number) whenever taking blood samples or administering medications or blood products.
[Scored at Standard PC.5.10, EP #4]
b. Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a “time out,” to confirm the correct patient, procedure and site, using active—not passive—communication techniques.
[Scored at Standard PC.13.20, EP #9]

2. Improve the effectiveness of communication among caregivers.

a. Implement a process for taking verbal or telephone orders or critical test results that require a verification “read-back” of the complete order or test result by the person receiving the order or test result. [Scored at Standard IM.6.50, EP #4]
b. Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to use.
[Scored at Standard IM.3.10, EP #2]

3. Improve the safety of using high-alert medications.

a. Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units.
[Scored at Standard MM.2.20, EP #9]
b. Standardize and limit the number of drug concentrations available in the organization.
[Scored at Standard MM.2.20, EP #8]

4. Eliminate wrong-site, wrong-patient, wrong-procedure surgery.

a. Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available.
b. Implement a process to mark the surgical site and involve the patient in the marking process.

5. Improve the safety of using infusion pumps.

a. Ensure free-flow protection on all general-use and PCA (patient controlled analgesia) intravenous infusion pumps used in the organization.

6. Improve the effectiveness of clinical alarm systems.

a. Implement regular preventive maintenance and testing of alarm systems.
b. Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.

7. Reduce the risk of health care-acquired infections.

a. Comply with current CDC hygiene guidelines.*
b. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection.

Source: www.jcaho.org
* www.cdc.gov/handhygiene/

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> The Seventh Annual National Patient Safety Foundation Congress in Orlando, Fla., May 5-9, 2005. See www.npsf.org for details.

> AORN has produced tool kits for the implementation of JCAHO’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. See www.aorn.org for more information.