Part VII – The Universal Protocol for Preventing Wrong-Site, Wrong-Procedure and Wrong-Person Surgery

Follow the link to the Joint Commission’s Universal Protocol, print it and save it to your computer file for the client’s case. Create an electronic file for “research-medical” and save it. Print a copy and take it with you. Get to know this protocol. If you’re a member of a surgical team do the same. Get to know this protocol because it’s presently the gold-standard.

So how have I broken it down and boiled it down to the core? Let’s take a look at the UP because when understood it provides a framework for the surgical team to provide checks and cross checks on each other. There is nothing wrong with a nurse supporting a doctor, questioning the team and making sure the patient is receiving optimal care. Some may feel to do so encroaches on the Captain of the Ship doctrine, the surgeon’s authority, but when a patient’s health is at stake the doctor’s oath “to first do no harm” should prevail.

History of Captain of the Ship
What is the doctrine of Captain of the Ship? Captain of the Ship was first introduced into the law of negligence by the case of
McConnell v Williams, 361 Pa. 355 (1949). An obstetrician asked an intern "to be his assistant and take care of the baby at the time of the delivery." When the operation took place, it was a very difficult delivery, which required the obstetrician's complete attention. When the child was delivered, the obstetrician turned the child over to the intern for the purpose of tying the cord and applying a solution of silver nitrate into the infant's eyes. Applying silver nitrate was a regularly established practice in obstetrical cases and was required by the rules and regulations of the Department of Health of the Commonwealth of Pennsylvania. One of the nurses present in the operating room noticed that the intern filled the syringe and squirted the solution once into the child's left eye and twice into its right eye, putting too much of the solution into the right eye. Moreover, the nurse testified that the intern failed to irrigate the eye. The result was that the child lost sight in her right eye. The evidence showed that the insertion of silver nitrate was not a job which required any special skill and could have been performed by persons who were not educated in medicine in any way. [See Gene A. Blumenreich, JD. Powers & Hall, Boston, Mass., Legal Briefs, Captain of the Ship, Feb. 1993.]

See also Cahill, Court Upholds Captain-of-the-Ship Doctrine, The Doctor’s Advocate, Second Quarter 2008.

I’m not going to quote the Universal Protocol because I do not have permission from the Joint Commission to reprint it. As patients we can salute the Joint Commission and all those who participated in creating it, for a job well done. I’ll highlight those words and phrases that form the crux of the UP. As indicated I do not have permission to print the Universal Protocol so I’ll reference it by link and you can print a copy for your file. Do this before going on as you’ll need to reference it as you read on.

There is actually a quite a bit there to understand. If done right the chances of an incorrect site, procedure or patient being performed are considerably reduced. Now I know the study Brooks Schuelke discusses in his post, Wrong Site Surgery: Is the Standard of Care Enough?, but my guess is in those instances the time-out is not being performed properly and taken seriously. So let’s examine the pieces.

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

The Pre-operative verification process includes:

1. Identifying and reviewing all of the relevant documents and studies and making sure they are available prior to the start of the procedure.

2. Then making sure the team has reviewed those documents and studies.

3. Then making sure they are consistent with each other and with the patient’s expectations and with the team’s understanding of the intended patient, procedure, site and, as applicable, any implants.

4. If information is missing information or there are discrepancies those issues must be addressed before starting the procedure. In other words if the chart says right hernia and someone thinks the operation is on the left, you stop the surgery or don’t start it, then iron out the discrepancy.

5. This is an ongoing process of information gathering and verification, beginning with the determination to do the procedure, continuing through all settings and interventions involved in the preoperative preparation of the patient, up to and including the “time out”. Remember we haven’t yet conducted the time-out. That comes just before the start of the procedure.

Marking the operative comes next:

1. The purpose of marking the operative site is to identify unambiguously the intended site of incision or insertion.

2. The process is different for left and right surgical issues. For procedures involving right/left distinction, multiple structures (such as fingers and toes), or multiple levels (as in spinal procedures), the intended site must be marked such that the mark will be visible after the patient has been prepped and draped.

At this point the surgical team is ready to conduct the time out”:

1. Begin the time-out immediately before starting the procedure.

2. The purpose is to conduct a final verification of the correct patient, procedure, site and, as applicable, implants.

3. The time-out process includes active communication among all members of the surgical/procedure team.

4. A proper time-out requires it to be consistently initiated by a designated member of the team, conducted in a “fail-safe” mode. A fail-safe mode as herein described requires no further surgical action be performed until any and all questions or concerns are resolved.

And it’s that last requirement that has me wondering if the resistance to the time-out comes from egos and a slowing down of the surgery that would probably require fewer surgeries in a day’s time. Is it the physician’s ego that resists a nurse questioning the team’s progress or intended progress? Could it be one SHOULD take a step back and imagine being the “captain of this ship” then discovering this is the wrong patient or that the team surgically removed the one healthy lung or that everyone was involved in sterilizing a woman who didn’t ask to be sterilized. If you can imagine how you as a member of the surgical team would react then perhaps taking a time-out isn’t such a bad idea. Or having a nurse question a doctor about the patient’s identity isn’t about egos but the patient’s health and the surgical team’s reputation for first doing no harm.

Why Patient Safety? Answer: “Patients know that their ailments may not always be cured, but they don’t expect to be inadvertently harmed due to medical care. The “blame and train” approach to medical errors and close calls doesn’t work well.”

The American Medical Association, AMA, has created a Power Point presentation on Patient Safety: An Overview. As stated in that presentation, Why Patient Safety? Answer: “Patients know that their ailments may not always be cured, but they don’t expect to be inadvertently harmed due to medical care. The “blame and train” approach to medical errors and close calls doesn’t work well.” Several industries that perform critical functions have studied human factors and engineered the systems to avoid inadvertent mistakes, because in some industries any mistake can cost lives. Medicine is no different. Surgery is certainly no different. If you think so ask yourself if a left-right mistake would be acceptably shrugged off by the public in any of the following industries:

•Aviation – Did you mean for me to turn left?

•Space Flight – Well I thought you meant now.

•Nuclear Power – Oops, that was the wrong button.

•Air traffic control – Oh sorry, I meant right. I sometimes get confused.

•Consumer products - Oops I used the paint with lead in it. No one will notice.

•Pharmaceuticals (Okay maybe they have way too many problems to be listed.)

•Weapons production – Oh my did I forget to add the gunpowder?

•Automotive manufacturing – Are these the right brakes for a truck?

•Food preparation – Oh well, we really didn’t need decontamination today.

•Building design and construction – Oh my you mean it’s to have how many floors?

•Bridge building and design - I didn’t think those rivets would hold four tons.

•Ship and submarine construction and design – Oh sorry I used the wrong gaskets.

We are all human. And as humans we can make the simplest mistakes. For the patient it’s sometimes about living and dying. While the surgical team may get to go home following the surgery, the patient may not be so lucky.

"The medical license of a surgeon in New Jersey has been suspended after it was discovered by state regulators that he had removed the wrong lung from a patient and then attempted to conceal his error."


Fixing the “System” works better • Ex: A patient dies because he was given someone else’s anti-arrhythmic medication by mistake.

º Blaming the individual doesn’t prevent medication mistakes from recurring.

º Establishing computerized medication dispensation with use of bar coding is better.

Be safe, not sorry, and conduct a proper Universal Protocol. If for no other reason than to prevent being shown at 50 years of age that you have to re-learn left from right and how that makes you look - rather idiotic. ©

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