The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery: UP.01.01.01
Elements of Performance:
1. Implement a pre-procedure process to verify the correct procedure, for the correct patient, at the correct site. Note: The patient is involved in the verification process when possible.
2. Identify the items that must be available for the procedure and use a standardized list to verify their availability. At a minimum, these items include the following: - Relevant documentation (for example, history and physical, signed procedure consent form, nursing assessment, and pre-anesthesia assessment) - Labeled diagnostic and radiology test results (for example, radiology images and scans, or pathology and biopsy reports) that are properly displayed - Any required blood products, implants, devices, and/or special equipment for the procedure Note: The expectation of this element of performance is that the standardized list is available and is used consistently during the pre-procedure verification. It is not necessary to document that the standardized list was used for each patient.
3. Match the items that are to be available in the procedure area to the patient.
Element 1 Findings: * Nightingale Hospital has a Procedure Handoff Tool which deals with several of the main Elements of Performance as laid down in the JC standard UP.01.01.01. * There is a policy, Site Identification and Verification (Universal Protocol), in place which gives specifics as to where and how the marking of a procedural/invasive site should be completed, by whom and when, if possible to involve the patient/guardian.
Element 1 Recommendations: * The flow of information is not sequential; sequential flow leads to a simplified and easy to view “failure” indication. * All the required elements should follow the patient’s arrival process i.e. Arrival