Comments on: RI hospital commits fifth wrong-site surgery since January 2007 http://blogs.hcpro.com/patientsafety/2009/11/ri-hospital-commits-fifth-wrong-site-surgery-since-january-2007/ Sat, 20 Mar 2010 15:57:09 -0400 http://wordpress.org/?v=2.9.1 hourly 1 By: Sandra Stanley http://blogs.hcpro.com/patientsafety/2009/11/ri-hospital-commits-fifth-wrong-site-surgery-since-january-2007/comment-page-1/#comment-80 Sandra Stanley Wed, 04 Nov 2009 16:07:53 +0000 http://blogs.hcpro.com/patientsafety/?p=963#comment-80 The DOH is making a good effort to guide RI hospital toward a culture of safety and preventing never events. Hospital leadership should take a closer look at the Universal Protocol and write policy and procedure for surgical interventions specifically based on the UP.01.01.01, if policy is written, consider maybe revising it to include surgical checklists a "time out" or procedural pause where every individual in that operating room (including the surgeon)stops and properly identifies the patient, informed consent, hospital consents,procedure,identified proper surgery part by marking the site and everyone agrees that they have the correct patient, the correct site, the correct procedure, the correct consent etc. In addition, the hospital needs to look at its system process and not soley concentrate on individuals pertaining to the surgery department. Prevention strategies for wrong-site surgery events begin from the admission process and continue throughout the patient's stay. Every hospital is vulnerable to a never event and must ensure that performance improvement strategies like root cause analysis, a system review and other PI methodologies are held on near misses to catch the system process error before it reaches the status of a never event. Sandra Stanley RN Clinical Safety Specialist The DOH is making a good effort to guide RI hospital toward a culture of safety and preventing never events. Hospital leadership should take a closer look at the Universal Protocol and write policy and procedure for surgical interventions specifically based on the UP.01.01.01, if policy is written, consider maybe revising it to include surgical checklists a “time out” or procedural pause where every individual in that operating room (including the surgeon)stops and properly identifies the patient, informed consent, hospital consents,procedure,identified proper surgery part by marking the site and everyone agrees that they have the correct patient, the correct site, the correct procedure, the correct consent etc.
In addition, the hospital needs to look at its system process and not soley concentrate on individuals pertaining to the surgery department. Prevention strategies for wrong-site surgery events begin from the admission process and continue throughout the patient’s stay. Every hospital is vulnerable to a never event and must ensure that performance improvement strategies like root cause analysis, a system review and other PI methodologies are held on near misses
to catch the system process error before it reaches the status of a never event.

Sandra Stanley RN
Clinical Safety Specialist

]]>