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Surgical Patient Safety, Hospital Accreditation and the Checklist Board

Surgical Patient Safety, Hospital Accreditation and the Checklist Board-- A proven combination to reduce errors
 
August 4, 2015 – Doug Hall – Checklist Boards
 
Stop! That’s the wrong patient!
 
This exclamation is heard over 1000 times per year in the U.S.
Wrong patient, wrong procedure, wrong side, and retained tools and towels are the most common surgical errors. These preventable errors are referred to as Never Events, mistakes that should never happen. But, they do happen over 4000 times per year. There is a simple solution to have fewer or no Never Event occurrences.
 
The Joint Commission for hospital accreditation recently introduced guidelines to address the surgical errors of omission, commission and misidentification. The guidelines titled, The Universal Protocol, has three components:

  • Conduct a pre-procedure verification process to address missing information before starting the procedure. This is the first step to verify the correct patient, the correct procedure and correct side/site.
  • Mark the Procedure Site – At a minimum, mark the site when there is more than one possible location for the procedure. The mark is to be unambiguous and used consistently throughout the organization.
  • Perform a Time Out – Conduct a time-out immediately before starting the invasive procedure or making the incision.
The full-participation time-out is to be standardized.
During the time-out, team members confirm and agree with the following:
  • Correct patient identity
  • Correct site
  • The name of the procedure to be done
The Veterans Administration issued similar guidelines for their 169 medical centers and hundreds of clinics that perform invasive procedures. The VHA 1039 directive provides guidelines to ensure the right patient, right procedure, right side, and if applicable, that the right device/implant is used.
 
The solution to catch these surgical Never Events is a well-planned time-out process and a well-designed Checklist Board. 
Here is an example of a surgical time-out with a Checklist Board:
 
  • The Time-Out Team Leader calls for everyone’s attention
  • Full participation and silence is required
  • Each member announces their name and role
  • Each line item of the Checklist is confirmed as complete/correct
  • The process is stopped if any line item is not complete/correct
  • All members are encouraged to Speak-Up at anytime
  • Any announcements from the surgeon, anesthetist or nurse
  • After the procedure all members sign-off in the EHR that the Checklist Board was correct
 
“This simple time-out process along with a Checklist Boards will help prevent injuries and fatalities. They also produce positive feedback during Hospital Accreditation Surveys,” said Rick Taylor president of the Checklist Boards Corporation.  “Our custom checklist white board has sliders that are manually moved from red to green as you progress through your checklist. The entire team’s attention is focused on the wall mounted board, as the Circulator reads through and confirms the checklist. Once all indicators are green, the procedure starts. Our clients report positive recognition from their Joint Commission surveyors, including some Best Practices recognition for their efficient time outs.”
 
Adding a new patient safety tool and adding a new operating room culture is a big challenge. It is important to get input from a wide variety of sources when designing new procedures. As the use of surgical time-outs checklists become routine for every invasive procedure, we’re confident to see fewer errors and increased patient and staff  satisfaction.  A custom Checklist Surgical Time-Out board can help drive your continuous improvement process. See info@checklistboards.com
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Hospitals use checklists to reduce errors