| Good Morning MHS Patient Safety Champions, Did you know, according to The Joint Commission, from calendar year (CY) 2005 through the second quarter (Q2) of CY2016, 1,225 WSS incidents were reported to TJC’s SE database? The root causes of WSS can be found in both hospitals and ambulatory surgical centers in four distinct areas of focus: scheduling, pre-operative (pre-op)/holding, operating room (OR)/procedural area, and organizational culture. The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery includes the following three recommendations:
1. Pre-Procedure Verification: Conduct a pre-procedure verification to ensure the right patient and the right procedure. The Joint Commission standards recommend that patients are involved when possible.
This also includes the consistent use of a standardized list to confirm the availability of critical items for the procedure including relevant documentation, labeled diagnostic and radiology test results, and any required blood products, implants, devices and/or special equipment.
2. Mark the Procedure Site: Mark the procedure site to ensure the right side and place on the patient’s body.
3. Perform a Time Out: Perform a time out to confirm right patient, site and procedure as the final verification immediately prior to the procedure. Document the completion of the time-out.
Sentinel events can happen during any invasive procedure performed in any clinical setting. Achieving zero incidence of WSS may necessitate modifications to the facility’s safe surgery policy, procedures and checklists to address WSS risk points unique to certain specialties, service lines, and procedures.If you’ve found these tips useful and would like more information about special considerations for dental, dermatology biopsies, nerve blocks, ophthalmology, radiology and spinal surgery, please download a free copy of the Eliminating Wrong Site Surgery and Procedure Events: A Guidebook for Inpatient and Ambulatory Facilities here. |
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If you have questions, please e-mail us at DHA.patientsafety@mail.mil.
Thank you,
DoD Patient Safety Program Team
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