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Promoting Patient Safety Through Preoperative Patient Verification

T duction

he Joint Commission on Accreditation of Healthcare Organizations (JCAHO) defines a sentinel event as “an unexpected occurrence involving death or serious physical or psycho- logical injury or risk thereof.”’ Since the intro- of the JCAHO policy on sentinel events in

1996,’ many hospitals have developed processes to pre- vent their occurrence. After analyzing its own current practices and reviewing the JCAHO literature, staff members at Spectrum Health, Grand Rapids, Mich, identified an opportunity to reduce potential risks asso- ciated with surgical intervention by improving verifica- tion of patient identification, scheduled procedure, and procedure side and site. Staff members developed and implemented a multilevel verification process. This arti- cle describes the improved process and its results.

DES4GNlNG A TASK FORCE The first step was to convene a multidisciplinary

task force to guide the design and implementation of the verification process. Representatives from all

Spectrum Health sites in which surgical procedures are performed (ie, two main hospitals and two free- standing surgical centers) were invited to participate. Task force members included surgeons, anesthesia care providers, perioperative and perianesthesia services managers, educators, staff members, and representatives from the risk management and con- tinuous improvement departments.

Task force members identified seven areas of potential risk related to accuracy:

surgery schedule, documentation received from physicians’ offices, preoperative documentation, preoperative checklist, surgeon interaction with patients immediately be- fore surgery, surgical record, and identification and verification of scheduled proce- dure and procedure site.

Each task fake member was charged with designing a specific aspect of the process related to the identi-

A B S T R A C T At Spectrum Health, Grand Rapids, Mich, a process to verify

patient identification, procedure, and procedure side and site was developed and implemented to improve the current process. Focusing on risk-reduction strategies, an interdisciplinary task force revised the faciliws surgical site identification policy and improved the surgical scheduling form to highlight information for sided procedures. Task force members also designed a verification checklist to require the comparison of any procedure data to the physician’s order. This article describes these improvements and other methods that were estab- lished to ensure patient safety and reduce risk. Ongoing data collec- tion verifies that the process remains in place and that team members are compliant. The improved process maximizes patient safety because it allows for early intervention when any discrepancies are identified. AORN J 74 (Nov 2001) 690-698.

fied risks. Patients were included in the process by having them verbalize their understanding of the procedure and clearly mark the surgical side and site. Risk management staff members revised and enhanced the current patient safety policy to add greater specificity. The periopera- tive information systems manager and the surgical schedulers revised the scheduling process and collaborated with physicians’ offices to receive more accurate and appropriate patient informa- tion. Managers and staff members of the preoperative departments

B E C K Y B R O W N , R N ; M A R K A Y R I I P P A , R N ; K A T H Y S H A N E B E R G E R , R N

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developed a verification checklist. Intraoperative staff members designed a process for verbal consensus to take place in the OR. Continuous improvement department staff members developed measurement strategies and monitoring protocols to ensure the process remained appropriate and sus- tainable. Responsibility for educating staff members regarding all aspects of the new process fell to staff educators.

PATIENT SAFEW POUCY Spectrum Health did have a policy that addressed

patient identification and procedure verification; how- ever, task force members determined that it was not detailed enough and did not address all aspects of the newly developed verification process. Consequently, task force members drafted a new policy with the fol- lowing purpose:

To enhance the safely of surgicalpatients hav- ing procedures in the perioperative depart- ment by verzfiing the patientk identi& the scheduledprocedure, and procedure side with- in the perioperative period. This Verification, which includes verbal consensus, must occur prior to the surgical incision.’

The new policy clearly states the responsibility of all health care workers and the patient in relation to surgical side and site verification. It outlines the preoperative document review process and the verbal consensus process that occurs in the OR immediate- ly before an incision is made. Finally, it identifies the process that staff members must follow in the event they identify a discrepancy during verification.

SCHEDULING PROCESS Task force members identified two areas of

weakness in the surgery scheduling procedure- inconsistent enforcement and lack of uniformity among the four facility sites. They, therefore, selected a multidisciplinary group of staff members from all four sites and from physicians’ offices to consolidate and revise the current procedure scheduling forms. The group also revised the surgery scheduling proce- dure and recommended ways to ensure that the proce- dure was followed consistently by all staffmembers.

Scheduling forms. Group members first con- ducted a 30-day retrospective evaluation of the cur- rent forms to compare them to the published surgery schedule. The following problems were identified.

There was not a form for every scheduled procedure. Staff members at each facility used different forms with slightly different formats. Staff members at physicians’ offices used many, often obscure, abbreviations. Information about the procedure side and site was not submitted by physicians’ offices staff mem- bers in a consistent format or location on the forms. Staff members in some physicians’ ofices had developed their own forms, which resulted in incomplete information and increased error poten- tial because information was in a different order or difficult to find. At two sites, one form was used to schedule the original procedure and to communicate changes or cancellation of a procedure, making it difficult to determine which changes needed to be made. Information on the surgery schedule was not entered in a consistent manner. Some schedulers entered the word “left” or “right” at the beginning of the schedule, and others listed it at the end of the schedule. Many nonstandardized abbrevia- tions for words also were used.

Group members first developed a single surgery scheduling form that met all site requirements and could be used to schedule procedures at any site in the Spectrum Health system. They then created a dif- ferent form to be used for changing or canceling pro- cedures. This new form was referred to as an amend- ed surgery scheduling form. Both the scheduling form and the amended form were designed as a physician order form and required a physician signa- ture. In addition, the area on each form that was used to indicate the procedure to be performed was given greater prominence and included clearer directions about how to designate sided (ie, left, right, bilateral) procedural information, if applicable.

Scheduling procedure. Although staff mem- bers at all facility sites followed the same basic scheduling procedure, there were subtle differences at each site attributed to tradition, old habits, non- compliance, or lax enforcement of the procedure. Group members reviewed and revised the schedul- ing procedure and agreed to enforce the procedure consistently at all sites. The following points need- ed to be communicated clearly and enforced.

Only written communication is accepted for scheduled procedures. Oral scheduling is no longer permitted.

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Only approved scheduling forms can be used. Any old or unapproved forms will be returned for resubmission via the newly revised forms. The amended scheduling form must be used to make any changes to a scheduled procedure. Incomplete forms or forms with abbreviations of left, right, or bilateral will be returned. For consistency, the word “left,” “right,” or “bilat- eral” must appear first for any sided surgical pro- cedure description.

Copies of the new forms, along with a cover letter explaining the changes and how the new procedure would be enforced, were distributed at the quarterly oftice managers’ meetings and to all physicians’ offices.

vwRuTlolycnEcKusl The checklist initially used the title of “pre-

flight” because it was modeled after the aviation industry’s strategy for enhancing air safety: Design of the verification checklist progressed through sev- eral phases.

The checklist outlines a logical, sequential series of events to ensure correctness and complete- ness of a patient’s preparation for surgery. Redundancy is built into the checklist by requiring that certain steps be checked by two RNs. All refer- ences to the procedure are checked against the physician’s order, which is considered the definitive reference point.

The Joint Commission has identified the verifi- cation checklist as a strategy to reduce the risk of wrong-site su~gery.~ The Joint Commission further defines the components of the checklist as including

direct observation of the marked operative site and all documents referencing the intended operative procedure and site, including the medical record, x-rays, and other imaging studies and their reports, the informed consent document, the operating room mcord, and the anesthesia record..”

A variety of preoperative checklists were used throughout Spectrum Health, each designed to fit the needs of various practice areas. The task force assigned a group of representatives from these areas to review these elements and identify which ones were essential for a verification checklist.

First drafi; The first draft of the verification checklist included two sections. The first section

comprised elements that needed to be present before the patient enters the OR (ie, name of the procedure as identified on the procedure scheduling form, presence of consents, presence and correctness of the patient’s identification bracelet, documentation of correct side and site of procedure).

The second section was designed to capture the essence of the verification process. The second sec- tion allowed for comparing the procedure as identi- fied on the procedure scheduling form, the surgery schedule, patient and family member confirmation, the marked site, the consent form, and patient histo- ry and physical examinations. Other documents, which could be used as verification if available, were medical evaluatiodclearance forms, physi- cian’s oftice and progress notes, and pertinent diag- nostic findings. An area for documenting the identi- fication and correction of any discrepancy during the verification process was included in the second section. Discrepancies were to be addressed and resolved before the start of each procedure.

To ensure the information was correct, each care provider (eg, preoperative planning nurse, admitting nurse, circulating nurse) documented information according to his or her interaction with the patient. The verbal consensus performed by sur- gery team members also was documented on the verification checklist. This first draft was used as a quality improvement data collection tool and was not added to the patient’s permanent medical record.

Final version. The final version of the verifi- cation checklist addressed the areas identified in the first draft; however, group representatives conclud- ed that the final version did not need to include three levels of verification for each element. This final version becomes part of a patient’s permanent documentation (Table 1).

VEllBALColYSElYSUSPR~ Verbal consensus is the final step in the verifica-

tion process. Verbal consensus (ie, verbal verification of patient identity, procedure, and procedure side and site) occurs in the OR before the incision is made and generally is initiated by the circulating nurse, The anesthesia care provider and surgeon must be present and verbally confirm patient data with the circulating nurse. Verbal consensus for all surgical patients is documented in the surgical record.

Despite extensive education of surgeons, anes- thesia care providers, and other surgical team

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Table 1 PREOPERATWE VERIFICATION CHECKLIST

Date stamp Procedure Date Time

Initial each line when verified or completed. Write not applicable (n/a) for those items that are not applicable.

Preoperative verification checklist Initial Initial Verification of procedure/side Comments

~-

- - - - Physician‘s order matches consent* - - - - - - Site marked by - patient - family member - other

Initial Initial Verification of the Dresence of Comments

Patient understanding confirms physician’s order Schedule coincides with physician’s order for sitehided procedure

Patient and/or family member verbalization coincides with consent* Diagnostic reports present coincide with sitehide (specify)*

-

Initial -

Initial

General consent for treatment (completed and signed) Consents for procedure (completed and signed) Blood consent (need for type and cross-match or type and screen) or refusal Sterilization consent (if applicable) Medicaid sterilization consent (if applicable) Other consents: Identification band on* History and physical examination report

Verification of the Dresence of other Comments

-~

- - - - - - Preoperative medications given - - - - NPO since - - Last void at - - Preps completed - - - -

Unresolved/outstanding issues

Valuables checklist: None Removed To DrOCedUle Given to

Allergy profile completed and in chart Laboratory results reviewed and in chart; abnormal results reported to: Electrocardiogram results reviewed and in chart; abnormal results reported to:

Patient profile, patient care summary, and graphics completed on chart

Antiembolism devices on (if ordered) Loose teeth? no - yes - specify

Orthodontic appliances/dentures - - Eye glasses - - Contacts - right - left Prosthesis - - Jewelry/earrings - - Hearing aids - right - left

-~

~-

- - Other: To procedure at via

Signaturehime Initials Signaturehime Initials Signaturehime Initials

* Indicates this must be verified by two RNs.

(Adupted from Pre-Procedure Verificcrtion Checklist [2000], with permission from Spectrum Heu/th, Grund Rupids, Mich)

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With physician education

came increased buy-in

and participation in the

verbal consensus process.

members, two primary barriers were encountered when creating the verbal consensus process. First, even though any team member could initiate the verbal consensus process, the burden became the circulating nurse’s responsibility. The period before incision is extremely busy for the circulating nurse, making initiating verbal consensus challenging. Second, achieving physician participation and buy- in was challenging. Some physicians did not appear to value the process as evidenced when attempts were made to involve them.

Task force members facilitated staff focus groups to identify barriers and solutions to verbal consensus. Focus group participants recognized that the verbal consensus process was efficient and brief when physicians were attentive and prompt in responding. Circulating nurses believed they would not have difficulty assuming the responsibility for verbal consensus if physicians would participate better.

Quality improvement committee members col- lected data about compliance with the verbal con- sensus process to educate physicians and to decrease the number of potential errors identified before pro- cedures. Some physicians became process champi- ons by helping educate their colleagues about the process. With physician education came increased buy-in and participation in the process.

MEASUmm STMVEGI#s AWDMONlTORlWO-

After the new process was developed, staff members were educated, and implementation occurred, task force members began monitoring the effectiveness of the change to the process. To enhance the success of the transition, all surgeons received a letter two weeks before program imple-

mentation. The letter reinforced the change and served as a reminder that only approved forms would be accepted. The letter also stated that verbal consensus of the patient, procedure, and procedural side and site must occur before an incision is made.

The methodology used to evaluate the risk reduction strategies was a concurrent audit of all patients scheduled for surgical procedures who entered the system through a preoperative process within 30 days. This eliminated two groups that were not part of the initial education process (ie, inpatients and patients who were admitted directly to the OR). In preparation for the audit, task force members developed a data collection tool (Table 2). It was designed to look different so it would not be confused as part of the patient’s permanent medical record. The tool was pink and had no prepunched holes or patient data stamp area. The preoperative nurse initiated the tool in the preoperative area. The tool remained with the patient in the OR and was completed by nurses accountable for the care of the patient.

After each tool was complete, penoperative nurse managers entered the data for their sites retro- spectively into an electronic spreadsheet. Twenty-six indicators (eg, surgeon; boarding slip sent; right, left, or bilateral position identified) were determined to be relevant in the success of the verification process.

Data were merged into a collective report. The expectation of 100% review of all outpatient sched- uled procedures for a 30-day period was enormous. Data were submitted; however, not all results were entered in a timely manner because of the time lim- itations involved. As a result, the rough data were evaluated within the time frame, but a comprehen- sive report was not available for two months.

RESULTS Of the 4,000 procedures reviewed, 10% were

eliminated because of incomplete information. Discrepancies that could be contributed to the new scheduling process were identified in 20% of the remaining 3,600 procedures. Forty percent of dis- crepancies were traced to information received from physicians’ offices. Remaining data did not provide information that was significant enough to identify a trend. Task force members developed the following action plan based on the data.

Share results of information at OR executive meetings, surgery section meetings, nursing staff meetings, and office managers’ meetings because

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Table 2 DATA COLLECTION TOOL-PREOPERATIVE PROCESS AUDIT

Audit number Date of procedure Surgeon

Location of procedure (circle one): Downtown East campus South campus Surgical center

Check one: - Scheduled - Add on within 24 hours

Boarding slip sent Y N Date received

If yes: Verified: Y N Right or left identified Y N NIA Procedure written Y N

Location verification checklist is initiated (check only one)

Downtown East campus South campus Surgical center - Spectrum Health outpatient center - PP -PP -Holding -Preoperative planning (PP) - Outpatient administration area - Holding O R -Patient holding -Patient holding - OR -OR -OR Side procedure section complete: Y N N/A

If yes, right, left, or bilateral identified: Y N Discrepancy identified: Y N

If yes, what? -Side - Procedure - Other, please explain

- Boarding slip - History and physical examination report - Surgery schedule -Medical evaluationlclearance - Patientbamily member confirmation -Physician’s office notes - Marking -Physician’s progress notes - Patient identification -Diagnostic information - Consent form V e r b a l consensus

How was discrepancy identified? (Check all that apply)

Documentation that discrepancy was corrected Y N

This report is prepared pursuant to, but not limited to, P.A.368 of 1978. This report is a review function and, as such, is confidential and shall be used only for the purpose provided by law and shall not be a public record and shall not be available for court subpoena.

(Adapted from Data Collection Tool: Pre-Operative Process Audit [2OCO], with permission from Spectrum H6w/h, Grand Rapids, Mich)

communication is essential. Share with staff members the expectation that the wording on the surgical consent must match the physician’s written order. Although the sur- gery schedule should be consistent with the con- sent, the schedule was not to be used as the source of information for the consent because often the surgery schedule needed to be abbrevi-

ated to get all the procedure information into a limited field. Reinforce with surgery schedulers the need to return improperly completed procedure schedul- ing forms to physicians’ offices. Schedulers were reminded of the important patient safety issues at stake and assured of administrative support during the transition period.

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Enlist the aid of the chief of medical staff to inter- vene with specific physicians and physicians’ oftices staff members who do not follow policy. N ~ O W the focus of the audit from completing scheduling slips and the verification checklist to

ms needed to be

accountable for hCOrpOrathlg

the veacation process obtaining and hocumenting verbal consensus and resolving discrepancies. Change-ihe vokme of data entry to 10% of all procedures versus 100%. The determination to only audit 10% of random surgical procedures

their practice allowed for a more realistic approach for data col- lection in a system where 44,000 surgeries are performed per year. Change the process for recording data to a data- base that allows for easier querying. managers’ meetings and a newsletter. The consis-

tent enforcement of the scheduling policy was EDUCATION

Education was critical to successfully imple- ment the process. All RNs needed to be accountable for incorporating this process into their practice. It was necessary for RNs to have an understanding of not only the structure but also the concept of verifi- cation, thus differentiating the process from a simple preoperative checklist.

Task force members facilitated live in-service programs. For consistency, one educator who had been involved with the task force scripted and devel- oped these programs. Objectives were that RNs would be able to identify

various components of the policy as it applied to their area of practice (eg, intraoperative versus preoperative), their role in completing the verification checklist, and mechanisms to use in the event of a discrepancy.

Elements for the in-service programs included a review of the site identification policy, the verifica- tion checklist, and the guidelines for use of the checklist. Sample documentation was provided. The checklist and policy were presented to staff members as a multilevel, multilayer verification tool used to consolidate documentation regarding verification of the patient procedure and procedure side and site. Additional information was presented indicating how patient safety is optimized and how the process is supported by JCAHO recommendations. To track these programs, attendance records, program titles, and objectives were consistent across all areas in which the policy was implemented.

Education for staff members at physicians’ offices was accomplished through quarterly ofice

believed to be the most effective to change ofice practices. The vice president for medical affairs contacted any physician whose ofice staff members were identified as particularly problemat- ic, and an immediate change in behavior was noted.

mREApwcAlloms This process began with patients who entered the

system through the preoperative departments. Quality monitoring of the process implemented with these patients will provide data to improve the process for implementation across all patient populations.

The final step of implementation will be to intro- duce the process to nonsurgical procedural areas (eg. cardiac catheterization laboratory, invasive radiology department, gastrointestinal laboratory). Certain non- surgical areas will have different circumstances, which will require revision of the process.

SUMMARY The Joint Commission offers the following

strategies for reducing the risk of wrong-site surgery. Clearly mark the surgical site and involve the patient in the marking process. Require oral verification of the correct site in the OR by each member of the surgical team. Develop a verification checklist that includes all documents referencing the surgical procedure and site, including the medical record, x-rays and other imaging studies, informed consent docu- ments, surgical records, anesthesia records, and direct observation of the marked surgical site.’

These strategies have been incorporated into the process at Spectrum Health and have proven to reduce the risk for sentinel event occurrence and to

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increase the quality of care provided for patients. Ongoing data collection verifies that the process remains in place and that team members are compli- ant. The improved process maximizes patient safety, as it allows for early intervention when any discrep- ancies are identified. A

Becky Brown, RN, MSN, is the clinical manager: outpa- tient services, Spectrum Health, Grand Rapids, Mich.

MarKay Riippa, RN, is the clinical manager; surgical critical carehedical critical care, Spectrum Health,

N O T E S

policy,” Joint Commission on Accreditation of Healthcare Organizations, http:llwww.jcaho .org/sentineVsentevnt-frm.html (accessed 1 Oct 2001).

Joint Commission on Accreditation of Healthcare Organizations,

1. “Facts about the sentinel event

2. “Sentinel event policy,”

Grand Rapids, Mich.

Kathy Shaneberger, RN, MS, CNOR, is the director, perioperative services, Spectrum Health, Grand Rapids, Mich.

The authors wish to thank the following employees of Spectrum Health Care, Grand Rapids, Mich: Sylvia K. Baird, RN, MM, qualiq improvement coordinator; Pamela Hietbrink, RN, BSN, perioperative services information systems manager; Julie Ostrander, RN, BSN, clinical manager; outpatient center; Lori Wightman, RN, MSN, clinical site manager; and Deborah E. Williams, RN, BA, clinical site manager

http:l/www.jcaho.org/ptsafety-frm .html (accessed 1 Oct 2001).

of Scheduled Procedure and Procedure Side, Hospital-wide Clinical Policy #CPOL-100-SO7 13 (Grand Rapids, Mich: Spectrum Health, Oct 1 1, 2000).

Lesson: Aviation’s Safety

3. Identification and Verification

4. R Davis, “Medicine’s Flying

Prescriptions Land in Operating Rooms,” USA Todq, 19 Oct 1998, 1 D.

5 . Joint Commission on Accreditation of Healthcare Organizations, “Lessons learned: Wrong site surgery,” Sentinel Event Alert 6 (Aug 28, 1998).

6. Ibid. 7. Ibid.

Consumers Urged to Beware of Health Care Internet Claims Several false promotions made on the Internet have the Federal Trade Commission (FTC) concerned, according to a consumer education publication from the FTC. An article in “FTC Consumer Feature” states that the FTC and other law enforcement agen- cies have increased efforts to prevent the prolifera- tion of false health care claims on the Internet. These agencies are using the latest technology to identify fraudulent marketers. The FTC also is edu- cating consumers on how to shop safely online for health care products. The commission is encourag- ing people to speak with their physicians or other health care providers about the safe use of supple- ments and other alternative health products. The FTC also is urging people to report suspicious health claims to government authorities.

keters low-cost access to a large market. The cost is reasonable for both legitimate and fraudulent mar- keters to market their products online. Fraudulent health claims typically concern serious diseases (eg, AIDS, cancer, multiple sclerosis) and chronic condi- tions (eg, headaches, back pain). Promoters of health

According to the article, the Internet offers mar-

care products often use similar claims to lure con- sumers into buying their products. According to the article, consumers should be suspicious of health care marketers who

claim their product is a “scientific breakthrough,” “miraculous cure,” “secret ingredient,” or “ancient remedy”; claim their product is an effective cure for a wide range of ailments; use impressive-sounding medical terms; cite undocumented case histories of people who had “amazing” results; claim their product is available from only one source and require payment in advance; claim to have a “money-back” guarantee; or use web sites that fail to list the company’s name, address, telephone number, or other contact information.

For more information, contact the FTC at http:// www.fic.gov or (877) 382-4357.

“Health claims on the Internet: Buyer Beware, “ FTC Consumer Feature (June 200 I ) 1-2.

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