The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™ A Case Study 8th European Health Forum Gastein 2005 Karen H. Timmons President and CEO Joint Commission International

What the Universal Protocol Is The Universal Protocol is based on the fact that wrong site, wrong procedure, and wrong person surgery can be prevented. It is based on a consensus of experts and is intended to achieve the goal of eliminating wrong person, wrong procedure, and wrong site surgery.

“An orthopedic surgeon has a 1 in 4 chance of performing a wrong site surgery during a 35 year career.” AAOS Task Force, 1997

Why the Joint Commission Developed the Universal Protocol

Joint Commission’s Sentinel Event Database Collects reports from accredited organizations that have experienced a sentinel (adverse) event within their organization – organizations can report voluntarily or the Joint Commission could find out from another source Data from reports are collected, aggregated, and analyzed to identify root causes of adverse events The root causes are shared with all health care organizations The goal is to use the data to prevent similar errors from occurring in other health care organizations

Sentinel Event Experience to Date Of 3044 sentinel events reviewed by the Joint Commission, January 1995 through March 2005: 421 inpatient suicides 383 operative/post op complications 378 events of surgery at the wrong site 333 events relating to medication errors 225 deaths related to delay in treatment 148 patient falls 126 deaths of patients in restraints 108 assault/rape/homicide 89 perinatal death/injury 87 transfusion-related events 58 infection-related events 58 deaths following elopement 53 fires 50 anesthesia-related events 527 “other”

Types of “Wrong surgery” Cases

“Wrong Surgery” Cases by Setting

Root Causes of Wrong Site Surgery (1995-2005) Percent of events

Sentinel Event Alert Data and other information from the Sentinel Event Database are used to identify recommendations to prevent a specific type of adverse event These recommendations are published in Sentinel Event Alert, an online newsletter developed by the Joint Commission Each issue of Sentinel Event Alert includes expert commentary and recommendations on a particular topic Organizations are encouraged to use the recommendations in Sentinel Event Alert to prevent the occurrence of a specific type of adverse event Once we have analyzed common trends/patterns – issue Sentinel Event Alert. Provides mitigating strategies to prevent specific adverse events from happening.

Provided sample of these. Available on website. Periodic newsletter Identifies specific types of Sentinel Events Describes underlying causes. Suggest steps to prevent reoccur. Shares lessons learned.

Sentinel Event Trends: Potassium Chloride Events S. E. Alert # 1 February 1998 Conc. KCl Lab error Remove potassium chloride from open stock – pharmacy. Deaths did not do this.

Sentinel Event Trends: Medication Errors (% of Total) S. E. Alert # 11 November 1999 S. E. Alert # 19 May 2001 S.E.A. #23 Sept. 2001

Sentinel Event Trends: Reported Cases of Wrong-site Surgery W.S.S. Summit May 2003 NPSGs January 2003 U.P. S. E. Alert #24 December 2001 S. E. Alert # 6 August 1998

Other organizations also issued warnings on wrong site surgery. Statement on ensuring correct patient, correct site, and correct procedure surgery Bulletin of the American College of Surgeons Volume 87, Number 12, December 2002 AAOS launches 2003 public service ad campaign AAOS Bulletin February 2003, an American Academy of Orthopaedic Surgeons “Sign Your Site” initiative

Wrong Site Surgery Events Did Not Decrease! Despite these efforts, the number of wrong site surgeries reported to the Joint Commission’s database increased. By 2003, the Joint Commission was receiving 5 to 8 reports of wrong site surgery every month.

Wrong-Site Surgery Summit When? May 9, 2003 Why? To reach consensus on a universal protocol for eliminating wrong-site surgery Who? Leaders of all major professional associations that relate to the surgical process Results: Consensus on the following Wrong site, wrong patient, wrong procedure surgery is a significant, continuing problem A “universal protocol” is appropriate Teamwork is critical A multi-factorial approach is needed

Development, Approval, and Endorsement of the Protocol Draft consensus statement (Universal Protocol) developed and circulated among participants at the Summit Universal Protocol revised based on participant feedback Posted on JCAHO web site for comment Over 3000 responses received; further revisions made Approved by the Board of Commissioners (July 2003) Seeking endorsements of the Universal Protocol JCR Wrong Site Surgery seminar (December 2, 2003) Implementation of the Universal Protocol as a requirement for accreditation (July 1, 2004)

Provisions of the Universal Protocol Preoperative verification process Surgical site marking “Time out” immediately before starting Applicable to invasive procedures in all settings

Spreading Awareness Two Audiences Impacted Public Needs easy-to-read-and-understand information Health Care Professionals The Universal Protocol includes complex concepts and medical terminology Professionals require clarity and guidance in these types of communications

Spreading Awareness Over 50 professional health care associations with a total membership of more than 3 million doctors, nurses, and other medical professionals have endorsed the Joint Commission’s Universal Protocol and are spreading the word about preventing wrong site surgery These associations can best get the message of prevention out to the people who perform surgery or who are members of surgical teams

Speak Up Joint Commission has worked to create greater public awareness of wrong site surgery through the Speak Up Campaign Free downloadable brochure Free downloadable poster

Speak Up The brochure provides the public with steps they can take to prepare for surgery and questions they should ask their health care providers about their care. It encourages the patient to become an active member of the health care team.

Speak Up The poster was developed for health care organizations. It highlights the guidelines of the protocol.

Sentinel Event Trends: Wrong-site Surgeries Reported by Year W.S.S. Summit May 2003 NPSGs January 2003 U.P. S. E. Alert #24 December 2001 S. E. Alert # 6 August 1998 (1st Quarter)

WHO JCI Collaborating Centre on Patient Safety Solutions Component of World Alliance for Patient Safety WHO designated JCI as Collaborating Center for Patient Safety Solutions

Patient Safety Solution Definition The Joint Commission International Center for Patient Safety defines a patient safety solution as any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care.

Objectives of Center Identify current safety problems and already existing solutions Conduct gap analysis to determine highest priorities for development of solutions Establish collaborative network National agencies, ministries of health, NGS, etc. Share existing solutions Develop needed solutions Disseminate solutions

Objectives of Center Work with regional advisory committees to ensure appropriateness of solutions Asia, Middle East, Europe, Africa, Americas Understand barriers to solutions Develop strategies for dissemination

Solution Statement of Problem Identified Solution Applicability Background and Issues

Solution Strength of Evidence Implementation (resources needed) Sample Measures for Evaluation Selected References

For more information: The Joint Commission Resources Web Site www.jcrinc.com The Joint Commission on Accreditation of Healthcare Organizations Web Site www.jcaho.org Joint Commission International Center for Patient Safety www.jcipatientsafety.org