H&P
If an H&P is less than 30 days old, but older than 24 hours, you need a what.
What is an H&P update?
These items can be used to identify a patient.
What are:
name
DOB
MRN
If possible the patient is in this level of conciousness and participation when site mark takes place.
What is awake and aware and involved?
The LIP uses this to mark the procedure site as the approved mark.
Team pause is the final verification of these 4 things being correct.
What is: 1. correct patient. 2. correct site 3. correct procedure. 4. correct positioning
If an H&P is older than 30 days for a outpatient being admitted, you need a (what).
What is a whole new H&P?
Surgical safety checklist is a patient safety communication tool used by (who).
For surgery involving right vs. left, a level (spine), or specific digits, the intended site needs (what)
What is site mark?
The LIP performing the site mark, must be present for and participate in the Team Pause performed for each procedure he/she marks. True/false
True
Team pause is conducted in this location and when.
What is: the location where the procedure will be performed, prior to the start of the procedure.
Life-threatening emergencies do not require documentation of an H&P on the record before the procedure. True/false
True
The H&P will be documented within 24 hours of admission
In the OR, this person ensures the completion of the surgical safety checklist and documentation of the team pause.
Who is the RN circulator?
This can be used as an alternative to site marking.
What is the alternative site marking form.
The LIP who site marks the patient, must also be (what)
What is familiar with the patient and participating in the procedure.
In cases involving multiple procedures or more than one service, this will happen with the Pause.
What is the Team Pause will be repeated at the beginning of a new procedure?
The name of the policy containing H&P detailed requirements/rules.
What is contents of the Integrated Health Record (IHR)
Surgical safety checklist (Universal protocol) has three steps. The three steps are:
What are:
1. Pre-induction (pre-procedural verification and site marking)
2. Time out (team pause)
3. Debriefing
Site mark will be performed, before moving the patient to this location.
What is where the procedure will be performed?
This is when final verification of the site mark will happen.
What is during the Team Pause?
The 4 things contribute to the definition of a "fail-safe" mode.
What are:
1. All activity is suspended
2. All team members actively engaged, if not restart.
3. Anyone enter or exit during, restart.
4. Verbal agreement of all team members. If not must resolve.
Per OHSU policy an H&P exam may be focused. If focused, it will include an exam of these 3 things.
What are:
1. vital signs
2. cardiovascular exam
3. respiratory exam
Verification of the correct person, procedure and site will occur at the following intervals, as applicable to the sites, with the patient involved, awake and aware if possible: (5 different moments)
What is:
1. at the time procedure is scheduled
2. in the PAT clinic
3. upon admission to facility
4. before leaving pre-procedure area or upon entering procedure room
5. anytime care is transferred to another member of procedure team during procedure
These are the 8 exceptions to surgical site marking of any kind.
What are: 1. midline incision 2. single organs 3. same procedure on pairs. 4. endoscopy w/o intended laterality. 5. colonoscopy 6. An obvious wound that is the surgical site. 7. Emergent situations
The 5 instances when alternative site marking should be used.
What is: 1. Patients who refuse site marking. 2. Not easily marked sites (perineum). 3. Premature infants. 4. Teeth 5. Procedures where there are pairs with Different procedures being done on both.
The circulating nurse is the final gatekeeper to ensure these 4 things happen during the team pause.
What are:
1. Pause takes place in a fail-safe mode
2. All members participate
3. Pause is complete and all required elements are documented
4. This person has the authority to prevent the procedure from starting until the Pause is properly executed, also the responsibility to PSI and variances.