Performance of Correct Statement of the Problem and Impact. - PDF document

Performance of Correct Procedure at Correct Body Site Patient Safety Solutions CONTENT Performance of Correct • Statement of the Problem and Impact. • Associated Issues. Procedure at Correct • Suggested Actions. • Looking Forward. Body Site • Strength of Evidence. • Applicability. • Opportunities for Patients and Family Involvement. DR.SAFA A.BUCHEERY • Potential Barriers. General Dental Practitioner • Risks for Unintended Consequences. • Conclusions. Statement of the Problem Associated Issues and Impact � The effect of Joint Commission Universal � Wrong site procedures Protocol. � Contributing factors � Solutions � Impact of the problem: � combination of system organization commitment � Marking surgical site and modification of individual behaviours to improve � Wrong Site Surgery Summit the outcomes � Universal Protocol � apply to all areas where interventions are � Patient safety alert on correct site surgery performed Looking Forward Suggested Actions � Voluntary reporting of wrong site � Establish the performance of correct surgery at the correct body site as a health-care facility safety procedures priority � Ensure that health-care organizations have in � Incidents reports promote place protocols that: � Provide for verification multidisciplinary collaborations and � unambiguously mark the operative site with the patient’s system- based change in all procedure involvement areas � performance of “time-out”

Applicability Strength of Evidence � Hospitals � Analyses from the Joint Commission � Ambulatory care facilities Sentinel Event database and the American Academy of Orthopaedic Surgeons database. � Office-based surgical facilities. � Expert consensus Opportunities for Patients Potential Barriers and Family Involvement � Lack of surgeon “agreement” to the � Involve patients and family standardized approach � at the preoperative verification. � Failure to recognize risks in procedural � in the surgical site marking process . settings other than the operating room. � Reluctance of staff to question the surgeon when a possible error is identified. � The informed consent process Risks for Unintended Potential Barriers Consequences � Inadequate human resources and knowledge for � Inconsistent interpretation of an “X” facilitating processes to be challenged. marking to “operate here” versus “do not � “Automatic” behavior during the time-out operate here”. process � Inconsistency of Universal Protocol � Insufficient generally accepted research, data, procedures among several hospitals within a and economic rationale. geographic area. � Permanent tattooing of immature skin. � Perception of increased workload by staff and decreased efficiencies.

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