3/4/05njm

**Correct Patient Identification**

**Correct Surgical Procedure and Correct Surgical Site**

**DRAFT: Indian Health Universal Policy**

**PURPOSE:**

The primary purpose is to assure correct patient identification and
correct surgical site and procedure. The process of preoperative
verification of all invasive procedures will involve the patient or
guardian, the surgeon, nurses, technicians and anesthesia providers.  In
the event of an error this policy shall provide a guideline for
management.

**SCOPE:**

All patients undergoing an invasive procedure or operation at an Indian
Health Service Facility.  This policy shall be adaptable to those
procedures done outside the operating room arena (e. g., Intensive Care
Unit, Emergency Room, Endoscopy Suites and bedside procedures).

**PROCEDURE:**

Institutional strategy will emphasize three independent verifications of
the correct patient, the operative site, and the operative procedure. 
Patient or guardian collaboration will be used as an additional safety
measure.

The surgeon of record shall physically meet with the patient
preoperatively (prior to any sedation or analgesia if possible) and have
the patient verbally state (not confirm) the type and location of the
procedure to be performed.  The surgeon will document such verification
on the permanent medical record e. g., operative note, procedure note,
progress note.

The surgeon or nurse (in conjunction with the patient or guardian when
possible) should mark the surgical site using a permanent marking pen. 
This practice of "signing you site" shall be done in a manner that can
not be overlooked.

If a site can not be marked secondary to dressings, casts, or injuries
the mark will be located on the same side as close to the operative site
as possible.

Each facility will incorporate within their institutional policy the
process to verify the identity of the patient, the surgical site and the
procedure, immediately prior to surgery.  Check lists should include
documents such as the medical record, patient identification bands,
consent forms, imaging studies, and patient and family oral
confirmation. A final verification (in the operating room or wherever
the invasive procedure takes place) should be done by staff prior to the
incision being made, and documented.

Any consent, operative schedules and notes involving laterality will
spell out the side in its entirety i.e. right or left. Abbreviations on
consents and operative schedules will not be allowed.

Confirmation of identity of the patient, the site, and the procedure
will be verified by the anesthesia provider when applicable and noted on
the anesthesia record.

Confirmation of identity of the patient, the site, and the procedure
will be verified by the nursing personnel and documented on the
appropriate medical record.

Redundancy of verification is to be encouraged.

If there is a discrepancy between the patients' understanding of the
planned surgical site or procedure and the procedure indicated on the
history and physical, surgical schedule or consent the patient will not
be moved to the Operating Room until the discrepancy is corrected.

Fusions of spinal vertebrae and other operations on specific vertebral
levels must have the correct vertebra confirmed by x-ray during the
procedure.

No x-rays, charts or studies belonging to other patients will be brought
in to the Operating Room once the patient has entered.

**RECOGNITION OF SITUATIONS OF AMPLIFIED RISK**

Identification of situations in which medical errors are increased will
become part of each institution's policy.  Cases are noted to be of
increased risk when any of the following are identified:

> •        An emergency case
>
> •        Unusual physical characteristics of the patient including
> morbid obesity, deformity, paraplegia, and previous amputations
>
> •        Unfamiliar surgical instruments or suite
>
> •        Multiple concurrent surgeries or procedures on the same
> patient
>
> •        Orthopedic, urologic, or neurosurgical procedures
>
> •        Lack of complete information resources in the operating room,
> e. g., x-rays, charts
>
> •        Distractions in the operating room
>
> •        Staff fatigue

**RECOMMENDATIONS FOR MANAGEMENT OF ERRORS IN IDENTIFICAITON OF PATIENT
SURGICAL PROCEDURE OR SURGICAL SITE**

If during the course of a surgical procedure or after surgery has been
completed it is determined an error has occurred the surgeon will always
act in accordance with the patient's best interests and record the
events in the appropriate medical record.

> I.          If during a procedure under general anesthesia it is
> determined an error has occurred the surgeon should:
>
> •        Take appropriate steps to return the patient as nearly as
> possible to the preoperative conditions
>
> •        Perform the desired procedure at the correct site unless
> there are medical reasons not to proceed
>
> •        Advise the patient and the patient's family as soon as
> reasonable of what occurred and the likely consequences
>
> II.         If the procedure is performed under local and the patient
> is able to comprehend what has occurred and can give informed consent
> the surgeon should:
>
> •        Take steps to return the patient as nearly as possible to the
> preoperative state
>
> •        Advise the patient of the situation and recommend to the
> patient the appropriate course under the circumstances in the
> surgeon's best judgment
>
> •        Truthfully answer any relevant questions and proceed as
> directed by the patient.
>
> III.       If the error is discussed after the procedure has been
> completed the surgeon should advise the patient and family and
> recommend and immediate plan to help rectify the mistake unless there
> is a medical reason not to proceed.

The above policy will be adapted to bedside procedures as well as
procedures in the intensive care unit and emergency department.

Organizational structure should reflect adherence to this policy and
mandate compliance.  Ongoing quality assurance and monitoring should
reflect incorporation of this policy.

HB 3/3/05