Saturday, September 02, 2006

"Time outs" before surgery bolster patient safety

Despite the widespread media attention that wrong site surgeries receive, they are very rare.

The rate, according to a recent study in published in the Archives of Surgery, is 1 in every 112,994 operations.

But that one case can irreparably harm the patient, ruin a hospital's reputation and potentially end a physician's career.

Last year, healthcare institutions reported 84 wrong site or wrong patient surgeries to the Joint Commission on Accreditation of Healthcare Organizations.

"That number might seem small," said Peter Shea, MD, Medical Director at Backus Hospital. "But anything more than zero is unacceptable."

At Backus, just prior to any surgical procedure, medical and nursing personnel conduct a final verification process, which includes a deliberate pause (a "time out").

[Learn more about this by downloading JCAHO's "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery" here].

In this process, all members of the surgical team stop and confirm the correct patient, procedure and site.

Prior to transporting a patient to their procedure room, the physician marks the site of the procedure with the word "Yes" or with the physician's initials -- a process in which the patient is involved whenever possible.

Once in the procedure room, one member of the team reads the informed consent aloud while anesthesia checks the patient's hospital armband for the name, date of birth and medical record number, and all members of the team actively communicate to confirm that they are performing the right procedure on the right patient in the correct location on the body.

"We must always remain vigilant, and realize how important it is to follow our established patient safety protocols," said Karen Long, Vice President and Chief Nursing Officer at Backus. "The 'time out' process is very important."

Mary Bylone, RN, Assistant Vice President of Patient Care Services and Patient Safety Officer, said it is essential that all members of the surgical team participate in the "time out" process, each and every time.

"Not taking the time to do so can result in a major mistake," Ms. Bylone said.

According to Judi Goldberg, RN, Clinical Educator for Surgical Services, the Surgical and Special Procedures, Patient Safety Process for Patient Identification/Procedure/Site Verification policy and checklist have been used throughout the hospital since February 2000 wherever surgeries and invasive procedures are performed. The policy also requires making sure the correct x-rays, positioning supplies, implants and equipment are available prior to the start of the procedure.

"Patient safety must always be our first priority, and all members of the team are encouraged to speak up if they have concerns," Ms. Goldberg said.

Anyone with questions about the National Patient Safety Goals, or suggestions to help Backus improve patient safety, can call Ms. Bylone at 860-889-8331 ext. 2771 or Joe Hughes, Director of Quality Improvement, at 860-889-8331 ext. 2345.

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