1. Hess, Cathy Thomas BSN, RN, CWCN

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In wound care, clinical and operational rules help maintain compliance with standards, and checklists can provide an audit tool to ensure that requirements have been followed. One example of using a checklist to help maintain compliance in the hospital involves a time-out, which is one of The Joint Commission's 2016 National Patient Safety Goals. Defined under UP.01.03.01, a time-out is performed before a procedure to verify the procedure, patient, and site. To comply with this standard, one must customize the hospital's policy and procedure, create a checklist for team members to follow, and institute and verify the checklist according to facility requirements. For example, when reviewing the Elements of Performance for UP.01.03.01 as documented by The Joint Commission, the following checklist could be used to ensure clinical and operational accuracy in this standard. Note that the hospital determines the amount and type of documentation required.


"The Universal Protocol applies to all surgical and nonsurgical invasive procedures. Evidence indicates that procedures that place the patient at the most risk include those that involve general anesthesia or deep sedation, although other procedures may also affect patient safety. Organizations can enhance safety by correctly identifying the patient, the appropriate procedure, and the correct site of the procedure.


The Universal Protocol is based on the following principles:


* Wrong-person, wrong-site, and wrong-procedure surgery can and must be prevented.


* A robust approach using multiple, complementary strategies is necessary to achieve the goal of always conducting the correct procedure on the correct person, at the correct site.


* Active involvement and use of effective methods to improve communication among all members of the procedure team are important for success.


* To the extent possible, the patient and, as needed, the family are involved in the process.


* Consistent implementation of a standardized protocol is most effective in achieving safety.



The Universal Protocol is implemented most successfully in organizations with a culture that promotes teamwork and where all individuals feel empowered to protect patient safety. An organization should consider its culture when designing processes to meet the Universal Protocol. In some organizations, it may be necessary to be more prescriptive on certain elements of the Universal Protocol or to create processes that are not specifically addressed within these requirements.


Organizations should identify the timing and location of the preprocedure verification and site marking based on what works best for their own unique circumstances. The frequency and scope of the preprocedure verification will depend on the type and complexity of the procedure. The 3 components of the Universal Protocol are not necessarily presented in chronological order (although the preprocedure verification and site marking precede the final verification in the time-out). Preprocedure verification, site marking, and the time-out procedures should be as consistent as possible throughout the organization.


Note: Site marking is not required when the individual doing the procedure is continuously with the patient from the time of the decision to do the procedure through to the performance of the procedure.


UP.01.03.01: Elements of Performance

The purpose of the time-out is to conduct a final assessment that the correct patient, site, and procedure are identified. This requirement focuses on those minimum features of the time-out. Some believe that it is important to conduct the time-out before anesthesia for several reasons, including involvement of the patient.


An organization may conduct the time-out before anesthesia or may add another time-out at that time. During a time-out, activities are suspended to the extent possible so that team members can focus on active confirmation of the patient, site, and procedure. A designated member of the team initiates the time-out, and it includes active communication among all relevant members of the procedure team. The procedure is not started until all questions or concerns are resolved. The timeout is most effective when it is conducted consistently across the organization.


Rationale for UP.01.03.01


1. Conduct a time-out immediately before starting the invasive procedure or making the incision.


2. The time-out has the following characteristics:


* It is standardized, as defined by the organization.


* It is initiated by a designated member of the team.


* It involves the immediate members of the procedure team, including the individual performing the procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning.


3. When 2 or more procedures are being performed on the same patient, and the person performing the procedure changes, perform a time-out before each procedure is initiated.


4. During the time-out, the team members agree, at a minimum, on the following:


* correct patient identity


* the correct site


* the procedure to be done


5. Document the completion of the time-out.


Note: The organization determines the amount and type of documentation."




The Joint Commission. Ambulatory Health Care Accreditation Program. National Patient Safety Goals effective January 1, 2016. Last accessed September 26, 2016.