Transcript The Universal Protocol for Preventing Wrong Site, Wrong

The Universal Protocol for
Preventing Wrong Site, Wrong
Procedure, and Wrong Person
Surgery™
A Case Study
8th European Health Forum Gastein 2005
Karen H. Timmons
President and CEO
Joint Commission International
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What the Universal Protocol Is
The Universal Protocol is based on the
fact that wrong site, wrong procedure, and
wrong person surgery can be prevented.
It is based on a consensus of experts and
is intended to achieve the goal of
eliminating wrong person, wrong
procedure, and wrong site surgery.
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“An orthopedic surgeon has a 1 in 4 chance
of performing a wrong site surgery during a
35 year career.”
AAOS Task Force, 1997
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Why the Joint Commission
Developed the Universal
Protocol
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Joint Commission’s
Sentinel Event Database
• Collects reports from accredited organizations that have
experienced a sentinel (adverse) event within their
organization – organizations can report voluntarily or the
Joint Commission could find out from another source
• Data from reports are collected, aggregated, and
analyzed to identify root causes of adverse events
• The root causes are shared with all health care
organizations
• The goal is to use the data to prevent similar errors from
occurring in other health care organizations
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Sentinel Event Experience to
Date
Of 3044 sentinel events reviewed by the Joint Commission,
January 1995 through March 2005:
421 inpatient suicides
383 operative/post op complications
378 events of surgery at the wrong site
333 events relating to medication errors
225 deaths related to delay in treatment
148 patient falls
126 deaths of patients in restraints
108 assault/rape/homicide
89 perinatal death/injury
87 transfusion-related events
58 infection-related events
58 deaths following elopement
53 fires
50 anesthesia-related events
527 “other”
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Types of “Wrong surgery”
Cases
Wrong patient
12%
Other wrong
site
19%
Wrong
procedure
10%
Wrong side
59%
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“Wrong Surgery” Cases by
Setting
Free-standing
ASU
5%
Hospital-based
ASU
53%
Inpatient OR
29%
ICU/ER/SPU
13%
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Root Causes of Wrong Site
Surgery
(1995-2005)
Communication
Orientation/training
Patient assessment
Availability of info
Procedural compliance
OR hierarchy
Percent of events
Distraction
0
10
20
30
40
50
60
70
80
90
100
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Sentinel Event Alert
• Data and other information from the Sentinel Event
Database are used to identify recommendations to
prevent a specific type of adverse event
• These recommendations are published in Sentinel
Event Alert, an online newsletter developed by the
Joint Commission
• Each issue of Sentinel Event Alert includes expert
commentary and recommendations on a particular
topic
• Organizations are encouraged to use the
recommendations in Sentinel Event Alert to prevent
the occurrence of a specific type of adverse event
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SENTINEL EVENT ALERT
A publication of the Joint Commission on
Accreditation of Healthcare Organizations
Issue One
2-27-98
Joint Commission
on Ac c reditation of H ealthc are Organiz ations
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
Phone: (630) 792-5800
New Publication
"The way to prevent
tragic deaths from
accidental intravenous
injection of concentrated
KCl is excruciatingly
simple - -organizations
must take it off the floor
stock of all units. It is
one of the best
examples I know of a
'forcing function' -- a
procedure that makes a
certain type of error
impossible."
Lucian L. Leape, M.D.
We are pleased to introduce the first issue of Sentinel Event Alert, a
periodic publication dedicated to providing important information relating to
the occurrence and management of sentinel events in Joint
Commission-accredited health care organizations. Sentinel Event Alert, to
be published when appropriate as suggested by trend data, will provide
ongoing communication regarding the Joint Commission's Sentinel Event
Policy and Procedures, and most importantly, information about sentinel
event prevention. It is our expectation and belief that in sharing information
about the occurrence of sentinel events, we can ultimately reduce the
frequency of medical errors and other adverse events.
Medication Error Prevention -- Potassium Chloride
In the two years since the Joint Commission enacted its Sentinel Event
Policy, the Accreditation Committee of the Board of Commissioners has
reviewed more than 200 sentinel events. The most common category of
sentinel events was medication errors, and of those, the most frequently
implicated drug was potassium chloride (KCl). The Joint Commission has
reviewed 10 incidents of patient death resulting from misadministration of
Sentinel Event Trends:
Potassium Chloride Events
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S. E. Alert # 1
February 1998
8
6
4
Conc. KCl
Lab error
2
0
1995
1996
1997
1998
1999
2000
2001
2002
2003
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Sentinel Event Trends:
Medication Errors (% of Total)
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S. E. Alert # 11
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November 1999
S. E. Alert # 19
May 2001
20
S.E.A. #23
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Sept. 2001
12
8
4
0
1995
1996
1997
1998
1999
2000
2001
2002
2003
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Sentinel Event Trends:
Reported Cases of Wrong-site
Surgery
100
90
80
70
60
50
40
30
20
NPSGs
January 2003
S. E. Alert #24
December 2001
W.S.S. Summit
May 2003
U.P.
S. E. Alert # 6
August 1998
10
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
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Other organizations also issued warnings on
wrong site surgery.
• Statement on ensuring correct patient, correct site, and
correct procedure surgery
Bulletin of the American College of Surgeons Volume 87,
Number 12, December 2002
• AAOS launches 2003 public service ad campaign
AAOS Bulletin February 2003, an American Academy of
Orthopaedic Surgeons “Sign Your Site” initiative
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Wrong Site Surgery Events
Did Not Decrease!
Despite these efforts, the number of wrong
site surgeries reported to the Joint
Commission’s database increased.
By 2003, the Joint Commission was
receiving 5 to 8 reports of wrong site
surgery every month.
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Wrong-Site Surgery
Summit
• When? May 9, 2003
• Why? To reach consensus on a universal protocol
for eliminating wrong-site surgery
• Who? Leaders of all major professional
associations that relate to the surgical process
• Results: Consensus on the following
– Wrong site, wrong patient, wrong procedure surgery is a
significant, continuing problem
– A “universal protocol” is appropriate
– Teamwork is critical
– A multi-factorial approach is needed
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Development, Approval, and
Endorsement of the Protocol
• Draft consensus statement (Universal Protocol)
developed and circulated among participants at the
Summit
• Universal Protocol revised based on participant
feedback
• Posted on JCAHO web site for comment
• Over 3000 responses received; further revisions made
• Approved by the Board of Commissioners (July 2003)
• Seeking endorsements of the Universal Protocol
• JCR Wrong Site Surgery seminar (December 2, 2003)
• Implementation of the Universal Protocol as a
requirement for accreditation (July 1, 2004)
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Provisions of the Universal
Protocol
• Preoperative verification process
• Surgical site marking
• “Time out” immediately before starting
• Applicable to invasive procedures in all
settings
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Spreading Awareness
Two Audiences Impacted
• Public
Needs easy-to-read-and-understand information
• Health Care Professionals
The Universal Protocol includes complex concepts
and medical terminology
Professionals require clarity and guidance in these
types of communications
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Spreading Awareness
• Over 50 professional health care associations
with a total membership of more than 3 million
doctors, nurses, and other medical
professionals have endorsed the Joint
Commission’s Universal Protocol and are
spreading the word about preventing wrong
site surgery
• These associations can best get the message
of prevention out to the people who perform
surgery or who are members of surgical
teams
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Speak Up
• Joint Commission has worked to create
greater public awareness of wrong site
surgery through the Speak Up Campaign
Free downloadable brochure
Free downloadable poster
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Speak Up
The brochure provides the
public with steps they can
take to prepare for surgery
and questions they should
ask their health care
providers about their care.
It encourages the patient to
become an active member
of the health care team.
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Speak Up
The poster was
developed for
health care
organizations. It
highlights the
guidelines of the
protocol.
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Sentinel Event Trends:
Wrong-site Surgeries Reported by Year
100
90
80
70
60
50
40
30
20
NPSGs
January 2003
W.S.S. Summit
May 2003
U.P.
S. E. Alert #24
December 2001
S. E. Alert # 6
August 1998
10
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 st2005
(1 Quarter)
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WHO JCI Collaborating Centre
on Patient Safety Solutions
• Component of World Alliance for
Patient Safety
• WHO designated JCI as Collaborating
Center for Patient Safety Solutions
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Patient Safety Solution Definition
• The Joint Commission International
Center for Patient Safety defines a
patient safety solution as any system
design or intervention that has
demonstrated the ability to prevent or
mitigate patient harm stemming from
the processes of health care.
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Objectives of Center
• Identify current safety problems and already existing
solutions
• Conduct gap analysis to determine highest priorities for
development of solutions
• Establish collaborative network

National agencies, ministries of health, NGS, etc.



Share existing solutions
Develop needed solutions
Disseminate solutions
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Objectives of Center
• Work with regional advisory committees to ensure
appropriateness of solutions

Asia, Middle East, Europe, Africa, Americas
• Understand barriers to solutions
• Develop strategies for dissemination
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Solution
• Statement of Problem
• Identified Solution
• Applicability
• Background and Issues
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Solution
• Strength of Evidence
• Implementation (resources needed)
• Sample Measures for Evaluation
• Selected References
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For more information:
The Joint Commission Resources Web Site
www.jcrinc.com
The Joint Commission on Accreditation of Healthcare Organizations
Web Site
www.jcaho.org
Joint Commission International Center for Patient Safety
www.jcipatientsafety.org
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