Disclosures To Report
To remain compliant with the
Accreditation Council for
Continuing Medical Education
(ACCME®) regulations, it is
necessary to disclose to my
audience that I am employed by
The Regional Medical Center of
Orangeburg & Calhoun Counties,
Orangeburg Surgical Associates

Surgical Safety
&
Infection Prevention
E. Arden Weathers, MD
Thursday, September 16, 2010
Universal Protocol

The Universal Protocol applies to:
 All surgical and non-surgical
invasive procedures.

Hospitals can enhance safety by
correctly identifying:
 the patient,
 the appropriate procedure
 the correct site of the procedure.
Universal Protocol

UP.01.01.01 – Conduct a pre-procedure
verification process.

UP.01.02.01 - Mark the procedure site.

UP.01.03.01 - A time-out is performed
immediately prior to
starting procedures.
TJC has kept the major principles of the original Universal Protocol in place
but has provided local hospital systems with more flexibility in implementing
them.
Pre-procedure Verification

UP.01.01.01
Purpose:
To make sure all relevant documents and related
information or equipment are:
Available prior to the start of the procedure
Correctly
identified, labeled, and matched to the
patient identifiers
Reviewed
and consistent with the patient’s
expectations and with the teams understanding of the
intended patient, procedure, and site
Timing (when this verification occurs) and Location (where
this verification occurs) is under local control.
Pre-procedure Verification
Elements of Performance
UP.01.01.01
1) Implement a pre-procedure process to
verify:
Correct Patient
Correct Site
Correct Procedure
Note: The patient is involved in the verification process
when possible.
Pre-procedure Verification
Elements of Performance
UP.01.01.01
2) Identify items that must be available for
procedure and use a standardized list to verify
their availability. At a minimum, these items
include the following:
 Relevant documentation (H&P, signed consent, nursing
assessment, and pre-anesthesia assessment)
 Labeled diagnostic and radiology test results
(images, scans, pathology, and biopsy reports)
 Required blood products, implants, devices, and/or
special
equipment is that the standardized list is
Note:
The expectation
and used
procedure
3) available
Match items
to beconsistently
available induring
procedure
area to
verification.
It is not necessary to document that the
the patient.
standardized list was used for each patient.
Mark the procedure site
Elements of Performance

UP.01.02.01
Purpose:
Marking the procedure site is one way to protect
patients.
Patient safety is enhanced when a consistent
marking process is used throughout the hospital.
Mark the procedure site
Elements of Performance
UP.01.02.01
1) Identify procedures that require marking of the
incision or insertion site.
At a minimum, sites are marked when there is more
than one possible location for the procedure and
when performing the procedure in a different
location would negatively affect quality or safety.
Mark the procedure site
Elements of Performance
UP.01.02.01
2) Mark the procedure site before the procedure is
performed and, if possible, with the patient involved.
3) The procedure site is marked by a licensed
independent practitioner who is ultimately
accountable for the procedure and will be present
when the procedure is performed.
Marking the surgical site can be done by the following individuals:
a) Operating surgeon
b) Participating resident
c) Participating licensed practitioner (including physician assistant or
nurse practitioner) with a collaborative or supervisory agreement with
the surgeon (Determination of this application is under local control.)
UP.01.03.01
Time-out
Time out is performed immediately
prior to starting procedures

Purpose:
To conduct a final assessment
that the correct patient, site and
procedure are identified.
During a time-out, activities are suspended so that
team members can focus on active confirmation of the
patient, site and procedure.
Time-out
Elements of Performance
2)
UP.01.03.01
The time-out has the following characteristics:
 Standardized (as defined by the hospital).
 Initiated by a designated member of the team.
 Involves the immediate members of the procedure
team, including:
 Individual performing the procedure
 Anesthesia
 Circulating nurse
 OR technician(s)
 Other active participants who will be
participating in the procedure from the
beginning.
Time-out
Elements of Performance
UP.01.03.01
3) When two or more procedures are performed
on the same patient, and the person
performing the procedure changes, perform a
time-out before each procedure is initiated.
Note: Two different teams = two different timeouts.
Or if hospital requires two consents = two timeouts.
Time-out
Elements of Performance
UP.01.03.01
4) During the time-out, the team members
agree, at a minimum on the followng:
 Correct patient identity
 Correct site
 Procedure to be done
5) Document the completion
of the time-out.
National Time-Out Day June 16, 2010
Safe Surgery Saves Lives

The goal of the Safe Surgery Saves Lives
Challenge is to improve the safety of surgical
care around the world by ensuring adherence to
proven standards of care in all states.

The WHO Surgical Safety Checklist has
improved compliance with standards and
decreased complications from surgery in eight
pilot hospitals where it was evaluated.
WHO Surgical Safety Checklist

In
The checklist identifies
three phases of an
operation, each
corresponding to a
specific period in the
normal flow of work.
each phase, the checklist helps teams
confirm that the critical safety steps are
completed before it proceeds with the operation
tRMC Surgical Care
Improvement Team
Surgical Safety Checklist
1
Surgical Care
Improvement Team
adapted WHO form to
align with The Joint
Commission 2009
Standards and our
facility policies
4 Made final changes
based on feedback,
inserviced all staff
and released housewide 6/15/09 for full
implementation
2
Rapid
Cycle
Piloted for one day in
SDS and one OR suite.
Involved staff by
requesting feedback &
providing several
educational inservices.
3
Edited form based on
staff feedback and
rolled out to SDS, all
OR suites, Radiology,
& Cath Lab for second
pilot.
Surgical Safety Checklist

18 revisions with 4 implementations before final
roll out.

Significant staff involvement.

was the featured Hospital for SCHA
Operation Safe Surgery Webinar in March 2009.

SCHA article regarding our process and
progress.
Opportunities for Improvement

Physicians continue to complain
about site marking

Still have to track down H&Ps

Still need communication tool
on the back of form for in-patients

Compliance with cases performed outside of the
operating room.
SCIP Core Measures

Beta Blocker Perioperatively

Perioperative Temperature Management

Prophylactic Antibiotic within an hour preoperatively

Prophylactic Antibiotic Selection

Prophylactic Antibiotic End within 24 Hours

Glucose Management Cardiac Patients (≤ 200 POD1 &
POD2)

Appropriate Hair Removal

Urinary Catheter Removed

Recommended VTE (Ordered & Received)
SCIP Pocket Card
Front
Back
Core Measure Pocket Card
Front
Back
“How long should you try? Until….”
Jim Rohn
“Many of the great
achievements of the
world were accomplished by
tired and discouraged men
who kept on working”
Author: Unknown