Bernard McDonnell, DO, a retired physician and current surveyor for Healthcare Facilities Accreditation Program, previously identified "20 Questions Surgery Centers Should Ask to Ensure an Acceptable and Effective Infection Prevention Program" and "20 Questions Surgery Centers Should Ask to Ensure an Effective Safe Medication Management Program." Here he identifies 14 questions surgery centers and other providers need to ask themselves to help ensure they perform proper patient identification before a procedure.
1. Do you use at least two identifiers? "The baseline is you always need to have a minimum of two identifiers," says Dr. McDonnell. "You can't just look at the patient's bracelet. You need a name, maybe an ID number, phone number, date of birth, an address. There has to always, be at minimum, two identifiers."
2. Do you always use the same identifiers? Standardize the identifiers you will use with every patient. "Don't have everybody doing whatever they want to do," he says. "Have a policy. Do it the same way every time. If you're going to do name and ID number, do name and ID number each time." Note: Never use room numbers as an identifier. This is because patients often change rooms, Dr. McDonnell says.
3. Are you involving the patient in the process? A critical component of an effective patient identification program is having the patient confirm the procedure and the side. It is important to note that this does not replace your identifiers. Confirming with the patient is in addition to the two or more identifiers.
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4. Do you mark the site? "There needs to be patient involvement in that as well," Dr. McDonnell says. "Use a thin marker and write 'yes' on, for example, the knee you're going to do."
5. Do your surgeons mark the site? "The surgeon must be involved — he or she must also mark that knee," Dr. McDonnell says. "Often they put their initials." Note: He says it's also not a bad idea to have the nurse mark the site as well. "It might seem like overkill but it would never hurt."
6. Are you taking additional steps to confirm proper site and side? This includes looking at the patient's H&P, boarding and x-ray or MRI. "These will serve as further confirmation that it's, for example, the right knee," Dr. McDonnell says.
7. Do you have a policy that addresses what you do if there is a discrepancy? "What if everything says the right knee but the patient says it's the left?" says Dr. McDonnell. "What do you do? You need to have a policy for that. You must be able to resolve that. If you can't resolve it, cancel the case. If everything says right side and patient insists it's the left side, I would say to bring the patient back another day. It's better to have a canceled case than a wrong site surgery."
8. Are you performing procedural timeouts for every case? This needs to happen in the OR before the patient is touched. "I would say the first thing you do is turn off music and don't have any distracters," he says. "Then you call the timeout. The timeout has to be called formally and that can't vary. You can't just have people not paying attention.
Everyone is quiet, everyone is paying attention to this. You go over the identifiers, confirm the side and the site, everybody agrees to the procedure you're doing. Confirm you have what you need to do the case — do you have any implants you need, any special equipment, special drills? When everyone agrees, you can then start the case."
9. Do you have a timeout policy? This should provide the exact steps the OR team will follow to ensure a proper timeout, steps that should never be deviated from.
10. Do you have a policy if there is a discrepancy during the timeout? Do you know how you would handle any disagreement about site or side? At this point the patient may be sedated. What steps will you take? You should have a policy to address this as well, Dr. McDonnell says.
11. If you do spine cases, how do you identify levels? Most cases will involve the left or right side but that is not the case for levels of the spine. "How do note that you're going to do an injection at L2/L3 or at L4/L5?" Dr. McDonnell says. "The identifier and verification has to include multiple levels in the spine. How do you make sure you're going into the right area?" You need a policy addressing these cases.
12. Are your anesthesiologists involved in patient identification? Anesthesia should do its own identification when the patient is in receiving. "Anesthesiologists usually come and interview the patient and they do their own method of identifying the patient then," Dr. McDonnell says. "But anesthesia should also then be a critical part of the formal timeout process. Everyone in the room should be a part of the timeout: surgeon, scrub nurse or scrub tech, circulating nurse, the anesthesiologist or CRNA, a resident — everyone is a part of it and everyone agrees on site and side before the procedure starts."
13. Do you document that the timeout has been completed? "That's always documented in the OR record," Dr. McDonnell says. "While you're not going to put every little detail in the OR record, you're going to want to put that the timeout was completed and the time it was completed." The OR record should also always have listed the people in the OR.
14. Is everything you do concerning patient identification standardized? "Standardization helps prevent mistakes," Dr. McDonnell says. "And you can't become complacent with this, ever. People do make mistakes and it's because they're cutting corners and they're not following the steps listed here."
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