1. 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

2. 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.

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

4. Why the Joint Commission Developed the Universal Protocol

5. 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

6. 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”

7. Types of “Wrong surgery” Cases

8. “Wrong Surgery” Cases by Setting

9. Root Causes of Wrong Site Surgery
( )
Percent of events

10. 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.

11. 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.

12. 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.

13. 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

14. 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

15. 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

16. 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.

17. 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

18. 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)

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

20. 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

21. 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

22. 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

23. 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.

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

25. 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)

26. 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

27. 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.

28. 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

29. 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

30. Solution Statement of Problem Identified Solution Applicability
Background and Issues

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

32. For more information: The Joint Commission Resources Web Site
The Joint Commission on Accreditation of Healthcare Organizations Web Site
Joint Commission International Center for Patient Safety