Ori Prereq 2 - ST

Universal Protocol

• The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery was approved by the Joint Commission in July 2003
• A wrong procedure or a surgery on the wrong site or personis a sentinel event (an unexpected occurrence involving death or serious physical or psychological injury), trackedthrough the JCAHO sentinel event database
• In 2023, wrong surgery accounted for 8% of the total 1,411reported sentinel events (tied with unintentional retention of a foreign object for second most frequently reported sentinel event, second only to falls)
• Prevention of sentinel events involves:

• Positive patient identification several standardized times before the procedure
• Appropriate site marking
• A thorough time-out procedure

Before Transport to the OR

• The following should be confirmed/verified prior to transporting to the OR:
• Patient identification
• Scheduled procedure (boarded procedure and patient's confirmation)
• Consents, H&P/VPEC, X-rays or other imaging, site marking
• Availability of implant (if required)
• Availability of blood (if ordered)
• Patient/caregiver responses must match that listed on paperwork (and the site marking if applicable)

Site Marking

• Site marking must occur if a case involves a laterality or level
• Site/side marking is performed by a licensed independent practitioner who is ultimately accountable for the procedure and is present when the procedure is performed
• Surgeon must mark the site:

• With his/her initials (NOT an "X" or "Yes")
• Using an indelible (permanent) marker to ensure markings are still visible after skin prep
• Prior to the patient entering the OR suite

• Site(s) marked with patient/caregiver participation (e.g., verbal confirmation or the act of pointing)

Pre-op Patient Identification

• Always verify a patient’s identity using at least two identifiers
• Pre-op, patient or caregiver states their full name and date of birth

• Also ask them to state the planned procedure (should match that indicated on the consent)

• The nurse verifies that the name and date of birth on their identification bracelet, patient labels, and consent document match the patient’s response

• Also verify the medical record number is consistent between these items
• Name, date of birth, and medical record number should be verified after printing new identification bracelets and patient labels

Intra-op Patient Identification

• In the OR and before the patient istransferred to the OR table, thepatient’s identity must be verifiedagain using:

• Patient ID bracelet
• Patient ADT labels
• OR Flightboard
• eStar is connected to this
• Populates patient information and the Time Out checklist

• If awake, involve the patient in theidentification process
• Anesthesia providers will scan the patient’s ID to access the anesthesia chart
• The case number is not an acceptable patient identifier (not listed on the Flightboard)
• If the original ID bracelet is removed in the OR, it must be replaced by printing a replacement and verifying it with another staff member against the Flightboard

Surgical Counts

• In 2023, unintended retention of a foreign object also accounted for 8% of the total 1,411 reported sentinel events (tied with wrong surgery for second most frequently reported sentinel event)
• Items to be counted

• Sponges
• Sharps
• Miscellaneous items small enough to be retained
• Instruments:
• When a cavity is entered (thoracic, abdominal, pelvic, retroperitoneal space, mediastinal space)

• When wound size is large enough (or could become large enough to retain an instrument)

Surgical Counts

• Exceptions to instrument count

• Wound size is too small to retain an instrument (and has no chance of becoming large enough to retain an instrument)
• Procedure involves continuous fluoroscopy and/or radiographic films are used prior to closure (images are reviewed and approved by the attending surgeon prior to the closure of fascia)

• Counting sponges, sharps, and miscellaneous items

• The binding strip of sponges must be broken and each fully separated from the others during count
• Packages of multi-pack needles must have cover paper removed and individual needles counted
• Each individual clip bar is counted in a multi-pack
• Each piece of a counted item must be counted separately (red rubber cut into three pieces must be counted as three pieces; cutting countable sponges is prohibited)

Surgical Counts

Standardized Softs, Sharps, Miscellaneous Count Sheet

Surgical Counts

Standardized Softs, Sharps, Miscellaneous Count Sheet

Surgical Counts

• Staff to perform counts

• Scrub person and licensed circulator count together and out loud, visualizing each item

• Location counting sequence per item type/group

• Start at the surgical site and immediate surrounding area
• Proceed to the mayo stand
• Proceed to the back table, and lastly
• Complete with items off the sterile field

Surgical Counts

• Reconcile count

• During closing instrument counts, the scrub person identifies an instrument as "working" or "on the field" if still in use
• The licensed circulator marks the count sheet to indicate the item needs to be reconciled
• These items are kept separate from items that were not used in wound closure until reconcile count is completed (where those items are counted once more to finalize the instrument count)

• The patient CANNOT leave the operating roomuntil all counts are finalized!

• Final instrument count cannot be considered complete until instruments used in closing the wound are accounted for once wound is closed (the reconcile count)
• The surgeon or fellow responsible for the patient care must remain in the room until all counts are final

Surgical Counts

Instrument Count Sheet

Surgical Counts

• Incorrect count

• Whenever a count is incorrect for a non-emergent case:

1. Inform the surgeon AND call your CSL or the Board Charge Nurse
2. Recount the item type/group
3. Open all bagged sponges
4. Search trash, linen, and floor

• Your CSL or Board Charge Nurse will support you and assist in searching for the item

• If the count remains unresolved, a portable X-ray must be done before the patient leaves the OR suite (not billable to the patient if ordered correctly)

Surgical Counts

• Considerations for incorrect count X-ray

• The X-ray must include the entire operative site
• The radiology technologist will give the circulatorthe Accession number for that image
• For main campus:
• The licensed circulator calls the Radiology Reading Room (VUH 1406) for a STAT read bythe most senior radiologist on duty (resident or faculty)

• The radiologist communicates on the call directly with the attending surgeon

• For off-campus locations like ambulatory where an attending radiologist is not available:
• The attending surgeon will review the X-ray

• The licensed circulator must document:

• Name of the person who interpreted the X-ray
• Finding of the imaging
• Accession number

Surgical Counts

• Additional reasons to X-ray

• When one or more of the following risk factors are present:
• Case is a Level 1 trauma (and the wound is closed)
• Case had an unexpected change in procedure
• One or more specialty teams performing unrelated procedures simultaneously
• Patient has a BMI of 40 or greater (50 or greater for Caesarian section)
• When any member of the surgical team expresses any level of concern for a potential retained surgical item

Surgical Counts

Initial Count

Surgical Counts

Closing Count

Section Complete!

Wound Closure

Closure of the wound occurs when the fascia is closed, mesh is implanted, or wound is left open to heal by granulation and/or skin grafts.

Counting expectations for temporary relief

For lunch or break relief of the scrub person or licensed circulator, a full count is not necessary but counted items should be accounted for with relief staff (e.g., brief the relief staff about what items are off the field, what items are in use, and other relevant details about the count)

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments

References

[Policy] Universal Protocol - Identification of Correct Patient, Procedure, Site/Side (Time Out)

Procedure Requirements Reference List for Universal Protocol, Identification of Correct Patient, Procedure, Site, and Side (Time Out)

[Policy] Informed Consent

[SOP] Clinical Handover Communication

[Policy] Patient Identification

[SOP] Periop: Patient Identification - Adult

[SOP] Antimicrobials for Surgical Prophylaxis: Adult Patients

The Joint Commission releases annual Sentinel Event Data Report (OR Manager, 2024)

[Policy] Intraoperative Circulator/Scrub Technician Handoff Communication

[Policy] Counts: Sharps, Sponges, and Instruments