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Correct Site, Correct Patient, Correct Procedure Verification Documentation Audit. Team Membership Paula Hindle, Vice-President Chief Nurse Executive Peggy Vorrier RN, MS Administrative Director Surgical Services Mary Altier RN, MSN Jeri Katsaros RN, BSN Gigi Marinakos-Trulis, Data Analyst.

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correct site correct patient correct procedure verification documentation audit

Correct Site, Correct Patient, Correct Procedure VerificationDocumentation Audit

Team Membership

Paula Hindle, Vice-President Chief Nurse Executive

Peggy Vorrier RN, MS Administrative Director Surgical Services

Mary Altier RN, MSN

Jeri Katsaros RN, BSN

Gigi Marinakos-Trulis, Data Analyst

department membership
Main Operating Room

Labor and Delivery

Newborn Nursery

BICU

4SICU

NICU

Special Procedures

Biopsy Lab

Cardiographics

EP Lab

Cardiac Cath Lab

Pulmonary Function Lab

Nuclear Medicine

GI Lab

Ultrasound

Breast Imaging

Dermatology

Pain Clinic

ENT Clinic

Oak Brook Terrace 1

LOC Surgery Clinic

Ambulatory Surgery Center

Cancer Center

Oral Health Center

Department Membership
opportunity statement
Opportunity Statement

There is an opportunity at LUHS to assure compliance with the 2004 National Patient Safety Goal of Universal Protocol for preventing wrong site, wrong procedure and wrong patient surgery.

Project goal: Improve the documentation rates for compliance with proper consents, site verification and time out procedures.

most likely causes identified
Most Likely Causes Identified
  • Lack of tool to monitor compliance with protocol
  • Misinterpretation of completion 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”
solutions implemented
Solutions Implemented
  • Site Verification checklist created November 2003.
  • Form revised twice during data collection period 4th quarter 2003-4th quarter 2004 due to feedback from key stakeholders.
  • Education sessions for key stakeholders
  • Invasive Procedure List (in-patient and out-patient) developed June 2004
  • Random sampling of verification checklists performed quarterly: 4th quarter 2003-4th quarter 2004
  • Quarterly reports to involved departments
results
Results
  • 5 data collection periods
  • 24-25 departments submitted forms for audits
  • Total N=5055
  • Data elements measured:
    • Consents signed, site marked, time out completed
data collection
Data Collection
  • Quarter 4 2003 N=562 6 departments
  • Quarter 1 2004 N=605 8 departments
  • Quarter 2 2004 N=539 10 departments
  • Quarter 3 2004 N=1564 25 departments
  • Quarter 4 2004 N=1785 24 departments
  • Total N for collection period 5055
  • The number of sheets audited have increased by 68% since inception of project.
  • The number of departments submitting forms have increased by 76% since inception of project.
slide8

Definition: Consent documentation compliance of departments that perform procedures that require that a consent is verified prior to start of procedure.

Data source: Original data extracted from site verification checklist by RN and data analyst.

Data analysis: LUHS system-wide performance is at 95%.Consent scores have improved 4.2% since inception of audit from 92-96%.

slide9

Definition: Site marking documentation compliance of departments that perform procedures requiring site marking.

Data Source: Original data extracted from site verification checklist by RN and data analyst.

Data analysis: LUHS site marking performance improved 24% from implementation of project to present (Quarter 4 2003-Quarter 4 2004). System-wide performance is at 86%.

slide10

Definition: Time out documentation compliance of departments that perform procedures that require a “time-out”.

Data source: Original data extracted from site verification checklist by RN and data analyst.

Data analysis: LUHS time out performance has decreased 8% since implementation of project to present (Quarter 4 2003-Quarter 4 2004). System-wide mean is at 96%. Re-education initiatives implemented 1st quarter 2005.

next steps
Next Steps
  • Provide on-going education to departments that require assistance with proper site marking and time out verification.
  • Monitor departments for compliance.
  • Report quarterly results to departments.
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