Universal Protocol
When the nurse is doing the pre-procedure verification process, these 2 documents related to the procedure all need to be checked and match.
What are:
Consent form, and OR schedule procedure
This is used as the "source of truth" during a Time Out.
What is the surgical consent
At any point in the verification process, if a discrepancy is discovered (ex. the consent does not match the procedure on the surgery schedule) this is the next step.
What is: The procedure/process is stopped and does not continue until the discrepancy is resolved with the participation of all members of the procedural care team
Completion of an discrepancy, concern and resolution report also should occur.
This is the correct site marking for the anesthesia provider prior to a block
What is: YES
Spine surgery has a 2 stage marking process.
True
SBMC has 3 phases of the Universal Protocol When and where are they performed?
All 3 must be complete and correct to get points.
What are:
Before Inducing anesthesia
Before starting procedure
Before leaving the OR at end of case
Dr. M is performing a mastectomy and Dr. V will be placing expanders on the same patient (but is not present at beginning of case).
In regards to the time out, when is it said and how does it differ from a single case?
When two or more procedures are being performed on the same patient, a time-out is performed to confirm each subsequent procedure before it is initiated.
Pre-procedure verification should be done by the team member and with this person.
What is:
With the patient involved, awake, and aware if possible.
Who can do the site marking?
Site marking is done by only the surgeon/proceduralist, with the patient involved, awake, and aware if possible.
SBMC policy" Site marking is the responsibility of the surgeon/physician or designee who is directly involved in the procedure and will be present at the time of the procedure is performed."
It is okay for a patient to refuse a site marking
True or False
True
If they refuse,use alternative site marking and document on refusal form
The debrief is performed at this time
When is: at the end of the surgical procedure, and before the primary surgeon and the patient have left the room
Dr. H will be doing a block in the OR, on the left knee prior to the surgical procedure.
He has already done appropriate site marking.
This needs to take place before he can do the block.
A Time Out for the block (and it needs to be documented in Op-time as an additional "pre-incision" time-out)
For patient's that do not speak English, this is the accepted way to perform your interviews
What is use a hospital supplied interpreter or video interpreter service when available.
Family members of the patient should not serve as the sole interpretation source.
Name 3 exceptions to the rule of site marking.
1. Premature infants (and any child age 4 and under)
2. When a patient refuses to allow marking of the site
3. Single organ cases (Appy, Chole, Hyster)
4. Interventional procedure cases in which the catheter/instrument insertion site is not predetermined
5. There is an obvious wound or lesion that is the site of the intended procedure (unless there are multiple wounds or lesions and only some of them are to be treated)
Using a marker on a premature infant may cause a permanent tattoo on their skin
True
It may cause a permanent tattoo, use alternative method per policy
Staff verifies the correct person (name and either DOB or MRN), correct site, and correct procedure at the following times (name at least 4).
What are:
Upon scheduling the procedure, Before any pre-admission testing and assessment, At time of admission/entry into the facility for procedure whether elective or emergent' Before the patient leaves the pre-op holding area or enters the procedure room, Before regional blocks, During surgical time-out, Anytime the responsibility for care is transferred to another member of the procedural care team at the time of, and during the procedure
During the Time-Out, everyone present in the procedural room is doing this.
What is: pause in all other non-critical activities to focus on active participation in the Time-Out
"all other activities shall be suspended, to the extent possible without compromising patient safety, so that all relevant members of the team are focused on the active confirmation of the correct patient, site, and critical elements"
Before interacting with a patient, healthcare personnel establish the patient's identify via this.
Confirming patient's name and either date of birth or medical record number both verbally and using the patient's armband
If the patient is having a procedure where they should be marked, but cannot be marked because they are refusing the surgeon needs to do this.
1. Has to document the patient is refusing traditional marking/cannot be marked and complete 'Refusal of side site marking form' before the case can proceed.
2. Use alternative method for site marking.
Only the RN can initiate the Time Out?
False
Any active person involved in the case can initiate the Time Out
Name 4 of the items that are discussed in a debriefing.
What are:
Final diagnosis, name of procedure performed for OR record, wound classification, need for X-ray, review of specimen, labeled and tests needed, equipment problems, post-op destination and call with any precautions,, key recovery concerns, images and stickers, studies removed for OR, PACU bypass report to destination.
The number 1 failure for a Time Out demonstration during a Joint Commission visit is?
Failure of the entire team to be actively engaged in the process without distraction. This includes any company reps, X ray techs or others in the OR at the time of the Time Out.
These things have to be completed prior to the patient entering the OR for all non-emergent cases.
What are:
1. H & P present including risks and benefits and interval note (unless already an inpatient)
2. Anesthesia note including interval if not done day of
3. Signed surgical/anesthesia consent including signatures/date/time for: patient, witness, surgeon, and anesthesia provider
This is the correct location of the word YES when a surgeon is marking the surgical site.
What is:
The mark is positioned to be visible after the patient has his/her skin prepped, is in his/her final position, and sterile draping is completed.
All Time-Outs performed need to be documented in the EMR.
True