Presentation on theme: "A Case Study 8th European Health Forum Gastein 2005 Karen H. Timmons"— Presentation transcript:
1The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™ A Case Study8th European Health Forum Gastein 2005Karen H. TimmonsPresident and CEOJoint Commission International
2What 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
4Why the Joint Commission Developed the Universal Protocol
5Joint 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 sourceData from reports are collected, aggregated, and analyzed to identify root causes of adverse eventsThe root causes are shared with all health care organizationsThe goal is to use the data to prevent similar errors from occurring in other health care organizations
6Sentinel Event Experience to Date Of 3044 sentinel events reviewed by the Joint Commission, January 1995 through March 2005:421 inpatient suicides383 operative/post op complications378 events of surgery at the wrong site333 events relating to medication errors225 deaths related to delay in treatment148 patient falls126 deaths of patients in restraints108 assault/rape/homicide89 perinatal death/injury87 transfusion-related events58 infection-related events58 deaths following elopement53 fires50 anesthesia-related events527 “other”
9Root Causes of Wrong Site Surgery ( )Percent of events
10Sentinel Event AlertData and other information from the Sentinel Event Database are used to identify recommendations to prevent a specific type of adverse eventThese recommendations are published in Sentinel Event Alert, an online newsletter developed by the Joint CommissionEach issue of Sentinel Event Alert includes expert commentary and recommendations on a particular topicOrganizations are encouraged to use the recommendations in Sentinel Event Alert to prevent the occurrence of a specific type of adverse eventOnce we have analyzed common trends/patterns – issue Sentinel Event Alert.Provides mitigating strategies to prevent specific adverse events from happening.
11Provided sample of these. Available on website.Periodic newsletterIdentifies specific types of Sentinel EventsDescribes underlying causes.Suggest steps to prevent reoccur.Shares lessons learned.
12Sentinel Event Trends: Potassium Chloride Events S. E. Alert # 1February 1998Conc. KClLab errorRemove potassium chloride from open stock – pharmacy.Deaths did not do this.
13Sentinel Event Trends: Medication Errors (% of Total) S. E. Alert # 11November 1999S. E. Alert # 19May 2001S.E.A. #23Sept. 2001
14Sentinel Event Trends: Reported Cases of Wrong-site Surgery W.S.S. SummitMay 2003NPSGsJanuary 2003U.P.S. E. Alert #24December 2001S. E. Alert # 6August 1998
15Other 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 2002AAOS launches 2003 public service ad campaign AAOS Bulletin February 2003, an American Academy of Orthopaedic Surgeons “Sign Your Site” initiative
16Wrong 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.
17Wrong-Site Surgery Summit When? May 9, 2003Why? To reach consensus on a universal protocol for eliminating wrong-site surgeryWho? Leaders of all major professional associations that relate to the surgical processResults: Consensus on the followingWrong site, wrong patient, wrong procedure surgery is a significant, continuing problemA “universal protocol” is appropriateTeamwork is criticalA multi-factorial approach is needed
18Development, Approval, and Endorsement of the Protocol Draft consensus statement (Universal Protocol) developed and circulated among participants at the SummitUniversal Protocol revised based on participant feedbackPosted on JCAHO web site for commentOver 3000 responses received; further revisions madeApproved by the Board of Commissioners (July 2003)Seeking endorsements of the Universal ProtocolJCR Wrong Site Surgery seminar (December 2, 2003)Implementation of the Universal Protocol as a requirement for accreditation (July 1, 2004)
19Provisions of the Universal Protocol Preoperative verification processSurgical site marking“Time out” immediately before startingApplicable to invasive procedures in allsettings
20Spreading Awareness Two Audiences Impacted Public Needs easy-to-read-and-understand informationHealth Care ProfessionalsThe Universal Protocol includes complex concepts and medical terminologyProfessionals require clarity and guidance in these types of communications
21Spreading AwarenessOver 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 surgeryThese associations can best get the message of prevention out to the people who perform surgery or who are members of surgical teams
22Speak UpJoint Commission has worked to create greater public awareness of wrong site surgery through the Speak Up CampaignFree downloadable brochureFree downloadable poster
23Speak UpThe 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.
24Speak UpThe poster was developed for health care organizations. It highlights the guidelines of the protocol.
25Sentinel Event Trends: Wrong-site Surgeries Reported by Year W.S.S. SummitMay 2003NPSGsJanuary 2003U.P.S. E. Alert #24December 2001S. E. Alert # 6August 1998(1st Quarter)
26WHO JCI Collaborating Centre on Patient Safety Solutions Component of World Alliance for Patient SafetyWHO designated JCI as Collaborating Center for Patient Safety Solutions
27Patient 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.
28Objectives of CenterIdentify current safety problems and already existing solutionsConduct gap analysis to determine highest priorities for development of solutionsEstablish collaborative networkNational agencies, ministries of health, NGS, etc.Share existing solutionsDevelop needed solutionsDisseminate solutions
29Objectives of CenterWork with regional advisory committees to ensure appropriateness of solutionsAsia, Middle East, Europe, Africa, AmericasUnderstand barriers to solutionsDevelop strategies for dissemination
30Solution Statement of Problem Identified Solution Applicability Background and Issues
31Solution Strength of Evidence Implementation (resources needed) Sample Measures for EvaluationSelected References
32For more information: The Joint Commission Resources Web Site The Joint Commission on Accreditation of Healthcare Organizations Web SiteJoint Commission International Center for Patient Safety