correct site correct patient correct procedure documentation audit l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Correct Site Correct Patient Correct Procedure Documentation Audit PowerPoint Presentation
Download Presentation
Correct Site Correct Patient Correct Procedure Documentation Audit

Loading in 2 Seconds...

play fullscreen
1 / 11

Correct Site Correct Patient Correct Procedure Documentation Audit - PowerPoint PPT Presentation


  • 280 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Correct Site Correct Patient Correct Procedure Documentation Audit' - emberlynn


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
correct site correct patient correct procedure documentation audit

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, MSGigi 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

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

Department Membership
opportunity statement

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.

most likely causes identified
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”
solutions implemented
Solutions Implemented
  • Education sessions for key stakeholders regarding use of tool
  • Random sampling of verification checklists performed quarterly: 4th quarter 2003-4th quarter 2005
  • Quarterly reports to clinical departments
data analysis
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.
form submissions
Form Submissions

The number of departments submitting forms for audit has increased by

77% since project inception.

slide8

Consents Properly Documented

Definition: Percent of appropriate documentation demonstrating the department is in compliance with the Operative and Invasive Procedure Verification policy. (#13.0015.6)

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%.

slide9

Site Verification Properly Documented

Definition: Percent of appropriate documentation demonstrating the department is in compliance with the Operative and Invasive Procedure Verification policy. (#13.0015.6)

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.

slide10

Time Outs Properly Documented

Definition: Percent of appropriate documentation demonstrating the department is in compliance with the Operative and Invasive Procedure Verification policy. (#13.0015.6)

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%.

next steps
Next Steps
  • Revision of form: 1st Quarter 2006 with implementation targeted for 3rd quarter 2006 collection period
  • Revision of Operative procedure policy: Quarter 2 2006
  • 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