1. Correct Site Correct Patient Correct Procedure Documentation Audit
Team Membership
Paula Hindle, RN, MSN Mary Altier RN, MSN
Vice President Chief Nurse Executive Nursing Quality Specialist
Peggy Vorrier RN, MS Gigi Marinakos-Trulis
Administrative Director Surgical Services Data Analyst
Jo Quetsch RN MA-OM Jeri Katsaros RN, BSN
Manager Operating Room Manager Same Day Surgery/PAR

2. Department Membership
Main Operating Room
Labor and Delivery
Newborn Nursery
BICU, NICU, PICU
4SICU, 2WICU, 2CCU
Special Procedures
Cardiographics
EP Lab
Cardiac Cath Lab
Pulmonary Function Lab
Nuclear Medicine
Ultrasound
GI Lab
Breast Imaging
Dermatology
Pain Clinic
ENT Clinic
Oak Brook Terrace 1
LOC Surgery Center
Ambulatory Surgery Center
Cancer Center
Oral Health Center

3. Opportunity Statement
There is an opportunity at LUHS to assure compliance with the 2005 National Patient Safety Goal of the Universal Protocol for preventing wrong site, wrong procedure and wrong patient surgery.
Project goal: Improve the submission and documentation rates for compliance with proper consents, site verification and time-out procedures.

4. Most Likely Causes Identified
Knowledge deficit regarding use of tool
Knowledge deficit regarding proper submission of form
Lack of understanding of
Universal Protocol
Which surgeries/procedures are included in protocol
Which surgeries/procedures require site marking
Number of personnel required for a “time-out”

5. Solutions Implemented
Education sessions for key stakeholders regarding use of tool
Random sampling of verification checklists performed quarterly: 4th quarter th quarter 2005
Quarterly reports to clinical departments

6. Data Analysis 9 data collection periods since inception
26-29 departments submitted forms for audits
Total sheets audited N=13,696
Data elements measured:
Consents signed, site marked, time-out completed.

7. Form Submissions
The number of departments submitting forms for audit has increased by
77% since project inception.

8. Consents Properly Documented
Definition: Percent of appropriate documentation demonstrating the department is in compliance with the Operative and Invasive Procedure Verification policy. (# )
Data Source: Original data extracted from LUHS Site Verification Sheets by RN and Data Analyst.
Analysis: LUHS performance is stable with a mean of 95%.

9. Site Verification Properly Documented
Definition: Percent of appropriate documentation demonstrating the department is in compliance with the Operative and Invasive Procedure Verification policy. (# )
Data Source: Original data extracted from LUHS Site Verification Sheets by RN and Data Analyst.
Analysis: LUHS mean performance is at 81%. Recent month data demonstrates improvement.

10. Time Outs Properly Documented
Definition: Percent of appropriate documentation demonstrating the department is in compliance with the Operative and Invasive Procedure Verification policy. (# )
Data Source: Original data extracted from LUMC Site Verification Sheets by RN and Data Analyst.
Analysis: LUHS performance is stable with a mean of 95%.

11. Next Steps
Revision of form: 1st Quarter 2006 with implementation targeted for 3rd quarter 2006 collection period
Revision of Operative procedure policy: Quarter
In-service to all key stakeholders: both inpatient and Ambulatory sites regarding revised form/policy
Monitor departments for compliance
Quarterly reports to clinical departments provide feedback on performance