The Medical City Universal

Protocol to Prevent Wrong

Patient, Wrong Site Procedures

A Test of True
Teamwork
 This is a one hour training
workshop!
 Brief Talk: 20 minutes
 Clarifications: 10 minutes
 Role play: 15 minutes
 Q and A: 10 minutes
 Take home messages: 5 minutes
60 minutes
This can happen to you!!!
 Patient is wheeled into the OR for
arthroscopy, sedated. His right knee is
prepped and draped. Surgeon finds out
later it’s the WRONG KNEE.
 Patient answers to wrong name when
called and gets a MRI of the lumbar spine.
He is for CT scan of the abdomen.
 Doctor writes “right” instead of “left
breast”. Patient is biopsied on the wrong
side.
 Why mix-ups can occur
The trip from nursing floors to the
Operating Room or Radiology
Department is a relay of patients
and patient information
performed by overloaded, time-
pressured, multi-tasking,
distracted doctors, nurses,
transport and admin staff.

At the procedure site,

moderated chaos reigns.
The goal of the Universal Protocol
 To eliminate wrong patient, wrong site
surgical, radiologic and other
procedures
 To establish team work among
members of the surgical / radiologic
team wherein any member of the team
feels accountable for the outcome of
the procedure and empowered to “SEE
IT, SAY IT, FIX IT”.
 Communication: the critical skill
targeted by the Universal Protocol
 Staff must ask patients their name, what
procedure they consented to and which site.
 Staff must ensure that every member of the
team gets the patient’s name, procedure and
site RIGHT.
 Staff must SPEAK UP if something feels or
appears wrong, no matter how silly they may
feel to say something.
 Communication: the critical skill
targeted by the Universal Protocol
SEE IT!
 Be alert to anything that feels or appears wrong

SAY IT!
 SPEAK UP without deference to authority or
seniority.
FIX IT!
 Stop, ascertain patient’s identity, the procedure he
consented to and which site.
 All members of the team must agree 100% before
going ahead with procedure.
The 3 components of the
Universal Protocol
 Preoperative verification
 Marking the operative site
 Time out just before performing the
procedure
Preoperative verification
With the patient fully conscious, NURSE
must ask
1. “May I know your name again?”

2. “What procedure are you scheduled to

undergo?”
3. “Which side (if bilateral) or site (if
multiple lesions or levels) will the
procedure be done?”
Preoperative verification
NURSE must endorse to transport staff
1. “Patient’s name as given by patient
matches our patient identifiers.”
2. “Scheduled procedure matches informed
consent signed by patient.”
3. “Side (if bilateral) or site (if multiple
lesions or levels) matches informed
consent.”
Preoperative verification
 NURSE must NOT depend solely on
doctor’s admitting orders or request for
procedure.
 They can be wrong.
 Confirm with the patient or relatives. This
is patient partnership carried out for a
very important reason: to avoid errors.
 If there is conflicting information, call the
AP immediately.
 Communication: the critical skill
targeted by the Universal Protocol
SEE IT!
 Be alert to anything that feels or appears wrong

SAY IT!
 SPEAK UP without deference to authority or
seniority.
FIX IT!
 Stop, ascertain patient’s identity, the procedure he
consented to and which site.
 All members of the team must agree 100% before
going ahead with procedure.
Marking the procedure site.
 MD doing procedure
must mark all cases
involving right/left
distinction, multiple
structures (fingers,
toes), multiple levels
(spine) or multiple
lesions
 Marking the procedure site.
 Done BEFORE
patient leaves pre-
procedure area /
ward
 Done with full
knowledge of patient
 Mark must be visible
after prepping and
draping
 Marking the procedure site.
 The Medical City
  standard mark is an
  arrow placed near or
at the intended OR
incision site with OR
arrow heads and a
circular mark around
the perimeter of the
lesion or organ to be
excised.
Calling for a TIME OUT
Before performing the                  All team
procedure, the surgeon or members must agree
radiologist must make a 100% with
declaration to the entire  - The patient’s correct
team
 Patient’s name is
identity
…………………                   - The correct
 He has consented to a planned procedure
………………… which will                   - The correct
be performed on the site of planned
……………(side / site). procedure
- The correct signed
informed consent for the
Calling for a TIME OUT
The following must certify that a Time Out
was declared by signing the time out
section of the checklist    
1. The patient’s anesthesiologist or
surgeon or radiologist
AND
2. The circulating nurse or radiologic
technologist.
 Communication: the critical skill
targeted by the Universal Protocol
SEE IT!
 Be alert to anything that feels or appears wrong

SAY IT!
 SPEAK UP without deference to authority or
seniority.
FIX IT!
 Stop, ascertain patient’s identity, the procedure he
consented to and which site.
 All members of the team must agree 100% before
going ahead with procedure.
Now let’s practice
We need 10 volunteers for scenario 1
 A patient
 A surgeon
 An anesthesiologist
 A nurse in charge
 A transport staff
 A PARU nurse
 A circulating nurse
 3 evaluators who will assess effectiveness of execution
of Universal Protocol
Scenario 1 (role playing time: 5 min)
 Patient is diabetic and is being treated for
sepsis and gangrenous foot (left). He is
due for amputation of the foot below the
knee.
 Act out the Universal Protocol at the
following scenes:
 Scene 1: the Nursing Floor
 Scene 2: PARU
 Scene 3: the Operating Theater.
Scenario 1 (group processing time:10 min)
 At end of simulation, evaluators and rest
of audience must rate effectiveness of
team members in complying with the
Universal Protocol.
 In which of the 3 scenes is relay of patient
information problematic? Why?
 Which parts of the Protocol are
challenging to execute? What system
changes are needed to address these
challenges?
Shall we practice some more?
We need 9 volunteers for scenario 2
 A patient
 A radiology consultant
 A radio resident
 A receiving clerk
 A radio tech
 A radio nurse
 3 evaluators who will assess effectiveness of
execution of Universal Protocol
Scenario 2 (role playing time: 5 min)
 Patient (not admitted) has multiple colloid
adenomatous goiter and is being referred
for ultrasound guided biopsy of the right
lobe.
 Act out the Universal Protocol at the
following scenes:
 Scene 1: the Radiology Reception Area
 Scene 2: the Radiology Procedure Room.
Scenario 2 (group processing time:10 min)
 At end of simulation, evaluators and rest
of audience must rate effectiveness of
team members in complying with the
Universal Protocol.
 In which of the 3 scenes is relay of patient
information problematic? Why?
 Which parts of the Protocol are
challenging to execute? What system
changes are needed to address these
challenges?
The 3 components of the
Universal Protocol
Successful relay of patient
information begins and ends
with team work.
Teamwork is critical in
 Preoperative verification
 Marking the operative site
 Time out just before
performing the procedure
 Communication: the critical skill
targeted by the Universal Protocol
SEE IT!
 Be alert to anything that feels or appears wrong

SAY IT!
 SPEAK UP without deference to authority or
seniority.
FIX IT!
 Stop, ascertain patient’s identity, the procedure he
consented to and which site.
 All members of the team must agree 100% before
going ahead with procedure.