Part V - What to read to better understand how to prevent wrong-site, procedure and patient surgeries.

We are now at the fifth part of this series. This post concerns the resources you'll need for understanding The Joint Commission and what it's written about how this problem, of wrong-site, wrong-patient and wrong-procedure surgical mistakes, can be avoided and prevented.

The Joint Commission has created and adopted the Universal Protocol. Read it. Understand it. Appreciate the problem.

Patients - Read it. Understand it. Appreciate the problem. Know how it should be carried out. If it's not being done properly, ask why not. Don't be afraid to ask questions. Don't be afraid to hurt someone's feelings or to offend the surgeon. Remember it's your body.

Lawyers - Read it. Understand it. Appreciate the problem. Know how it should be carried out. If you don't fully appreciate what's involved then associated with an attorney who does.

Surgeons and surgical staff - Read it. Understand it. Appreciate the problem. Know how it should be carried out. Get over it, this is the protocol you need to be following. If someone on the team isn't following it then ask questions and if they refuse to embrace the Universal Protocol, report them to your supervisor the hospital administrator. There is an excellent Sentinel Event Alert, Issue 40, July 9, 2008 titled Behaviors that undermine a culture of safety. Read it because it supports your position of how professional positions of power can be abused and ultimately undermine a culture of safety.

“Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions.(2) Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients.(7, 8, 11) All intimidating and disruptive behaviors are unprofessional and should not be tolerated.”

Remember, when the Universal Protocol isn’t being effectively utilized, it is the patient who is being exposed to unnecessary risks.

The majority of health care professionals enter their chosen discipline for altruistic reasons and have a strong interest in caring for and helping other human beings. The preponderance of these individuals carry out their duties in a manner consistent with this idealism and maintain high levels of professionalism. The presence of intimidating and disruptive behaviors in an organization, however, erodes professional behavior and creates an unhealthy or even hostile work environment – one that is readily recognized by patients and their families. Health care organizations that ignore these behaviors also expose themselves to litigation from both employees and patients. Studies link patient complaints about unprofessional, disruptive behaviors and malpractice risk.(13,14,15) “Any behavior which impairs the health care team’s ability to function well creates risk,” says Gerald Hickson, M.D., associate dean for Clinical Affairs and director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center. “If health care organizations encourage patients and families to speak up, their observations and complaints, if recorded and fed back to organizational leadership, can serve as part of a surveillance system to identify behaviors by members of the health care team that create unnecessary risk.””

Tomorrow I’ll list those organizations who have endorsed the Universal Protocol. Until then enjoy reading from this list. And don't forget to check out the National Desk at InjuryBoard where Christie Cole has an interesting article reporting on the nine wrong-site surgery cases in Utah during 2007. Nine Wrong-Site Surgeries Occurred in Utah Hospitals in 2007. ©

-  Universal Protocol For Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery

-  Implementation Expectations for the Universal Protocol for Preventing Wrong site, Wrong Procedure and Wrong Person Surgery

-  Operative – High – Risk Procedures – Sedation – Anesthesia – Procedures Requiring Surgical Site Marking

-  National Patient Safety Goals for 2004 – Ambulatory Care

-  National Patient Safety Goals for 2007

-  Facts about Universal Protocol including ? Endorsers of the Universal Protocol

-  Universal Protocol – FAQ

-  Sentinel Event Alert - Lessons Learned: Wrong Site Surgery, August 28, 1998

-  Sentinel Event Alert – Issue 24 – December 5, 2001 A follow-up review of wrong site surgery.

-  Human Factors Engineering Series – Righting Wrong Site Surgery

-  Sentinel Event Alert - Behaviors that undermine a culture of safety, Issue 40, July 9, 2008.

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