September 2019 HSC Section 1 Congenital and Pediatric Problems

Reprinted by permission of Jt Comm J Qual Patient Saf. 2018; 44(9):552-556.

The Joint Commission Journal on Quality and Patient Safety 2018; 44:552–556

Safety

Stop: A Valuable Addition

to

the Pediatric

Universal Protocol Thomas J. Caruso, MD, MEd; Farrukh Munshey, MD, FRCPC; Brea Aldorfer, MS, RN, CPHQ; Paul J.

Sharek, MD,

MPH

Problem Definition: The World Health Organization (WHO) guidelines and Joint Commission requirements state that the time-out component of the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery TM must be performed just prior to incision. A mock Joint Commission survey at one institution revealed that the time-out was performed prior to preparation and draping (P&D) of the patient, not afterward, representing both a patient and regulatory risk. Approach: The multidisciplinary perioperative quality improvement team at a freestanding, quaternary care, academic pediatric hospital led the development of a new time-out process. An enhanced pediatric Universal Protocol, which included a new component, the safety stop, was created. The safety stop occurred just prior to P&D of the patient, and the time-out was performed just prior to incision, aligning with WHO recommendations. After electronic correspondence and several pe- rioperative leadership meetings, the enhanced pediatric Universal Protocol was initiated. Compliance audits were performed to demonstrate comprehensive adoption. Outcomes: In seven operating room locations, 60 audits were completed in four weeks, with 96.7% (58/60) demonstrat- ing compliance with the new policy. During a subsequent Joint Commission accreditation survey, the enhanced pediatric Universal Protocol with inclusion of the safety stop was highlighted as a leading practice. Key Insights: Although initially it was believed that moving the time-out from prior to P&D to just prior to incision would be a simple solution, flow mapping the complete time-out process identified significant risk of wrong-site or wrong- patient surgery with this solution. This risk was exacerbated by the small body size of pediatric patients being obscured by draping on a typical operating room table.

procedure.” 3 (p. 11)

PROBLEM DEFINITION During the last decade,

confirming

the

correct

patient,

site

and

Joint Commission

requirements

and WHO

recommenda-

there

has

been marked

improve-

tions

state

that

the

time-out

is

to

be

performed

just

prior

1 The

ment

in

perioperative

surgical

safety.

development

incision,

after

preparation

and

draping

(P&D)

of

the

to

successful

implementations

of

surgical

safety

check- adverse being Safety “Safe

and lists

3–4 At

to minimize

surgical morbidity

and mortality.

patient

have

played

a

significant

role

in minimizing

institution, prior

to a

routine

Joint Commission accred-

our

in

the

perioperative

period,

the most

notable

events

itation

survey,

a mock

survey

recorded

that we

performed

Health

Organization

(WHO)

Surgical

the World Checklist.

time-out prior

to P&D

of

the patient, not

afterward

as

the

1–3 Introduced

in

2008

as

part

of

the

5

a patient

safety

and

regulatory

risk.

recommended, posing

the

checklist was 2009 . The

revised

in

Surgery Saves Lives” campaign,

Despite

evidence

to

the

effectiveness

of

the

Universal

the WHO Guidelines

for

Safe

Surgery

guidelines

adults,

there

continues

to be

implementation

Protocol with

10

“essential team will

objectives

for

safe

surgery,” beginning

feature

compliance

variability

to

the

Universal

Protocol

in

and

“The

operate

on

the

correct

patient

at

the

with

6 Stakeholder

hospitals. training,

disengagement,

absence

pediatric

site.” 3 (p. 10) One

of WHO’s

“highly

recommended”

correct

formal

and unreliable process

compliance mea-

of

as

“a

practice

that that

should

be

in

place

in

practices—defined

sures

contribute

to

the

lack

of

widespread,

standardized

operation” 3 (p. 7) —to meet the Universal Protocol. As

first

objective

is

the

every

6 Although

tailoring

the

Universal

Protocol

to to

adoption.

of

developed Universal Procedure,

and mandated

use

pediatric

population

has

been

reported

as

an

effort

the

The

Joint

Commission,

the

Protocol

for

by

7,8 no

compliance,

formal

recommended

pediatric

increase standard

Wrong

Site,

Wrong

and

Wrong

Preventing

from accredited bodies exists.

Incorrect and partial

TM is

Surgery

a

three-step

process

consisting

of

Person

of

the Universal Protocol

contributes

to

increased

risks

use

time-out. 4

verification,

site marking,

and

a

preprocedure The WHO complementary

in the perioperative pediatric population. 7

events

of adverse

guidelines

note

that

each

of

the

three

steps

“is of

Prompted

by of

both

the mock

Joint Commission

survey

and

adds

redundancy

to

the

practice

the

goal

reducing

patient

risk,

we

embarked

on

a

and

improvement

effort

to

develop

a

novel WHO

multidisciplinary

1553-7250/$-see front matter © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jcjq.2018.03.015

Universal

Protocol

that

aligned

with

pediatric

1