Implementing The Universal Protocol Procedure

In accordance with the World Health Organisation (WHO 2008) checklist and Local trust policies, a team briefing was held before the day’s list started. The checklist is part of a second Global Patient Safety Challenge initiative entitled ‘Safe Surgery Saves Lives’, aimed at reducing the number of surgical deaths worldwide and was launched in June 2008. This not

Before a procedure begins, the nurse anesthetist will discuss with a patient any medications the patient is taking as well as any allergies or illnesses the patient may have. This must be done so anesthesia can be safely administered. Nurse anesthetists then give a patient general anesthesia to put the patient to sleep so they feel no pain during surgery or they may administer a regional

The process is an action plan that tends to illuminate on the strategies to be employed with the purpose of reducing the risk of a similar sentinel event such as that of Mr. B’s scenario. It addresses the responsibility for the oversight, implementation, pilot testing, as well as timelines and strategies for the measurement of actions that are effective (Lewis et al, 2014). All the root cause analysis (RCA) findings conducted above should help in the determination of the appropriate action plan. The appropriate improvement plan in this scenario should encompass the reevaluation of the events that led up to the code blue of Mr. B. The plan should look at the staffing mix, if the licensed personnel are trained appropriately, the patient to nurse ratio in the ER and the types of patients that were in the ER at the time. When

Second, the nurse commences assessment with an evaluation of patient’s airway, breathing, and circulation for any signs of inadequate oxygenation and ventilation. One of the patients’ temperature was 102 F and the physician recommended pain medication (dilaudid) and it was administered instantly. The nurse gets vital signs and compare the result with intraoperative care. The nurse chart vital signs every 5 mins for the next 15mins, every 15mins for the next hour depending on the recovery state of the patient. I also noticed that for diabetic patients, the nurse checks for blood glucose and also compare result with intraoperative care unit result. Third, the nurse assess pain although the patients receive pain medication before surgery. Fourth, the nurse assess surgical site (dressings and drainage). Fifth, the nurse assess neurologic (level of consciousness, orientation, sensory & motor status, pupil size and reaction. Finally, the nurse assess gastrointestinal (nausea, vomiting, intake of

The current policy requires the attending surgeon mark the correct site for surgery with the patient confirming the site in the preoperative holding area prior to receiving any anesthesia. Currently a safety checklist is used during the time out process in the O.R. but the patient is sleeping. The expectation is the site marked by the surgeon and the patient will remain visible after the patient is drapped for the procedure. The National Patient Safety Agency (NPSA) in 2005 noted this to be an appropriate procedure.

With all of the possible problems that could occur during surgery, a wrong-site, wrong-patient mistake is one that should never arise. Nightingale Community Hospital (NCH) fully understands the importance of doing away with these errors and has set up protocol to work towards this goal. While the protocol is in place, it is not fully compliant with Joint Commission (JC) standards.

This Anaesthetic case study would describes and discussed the scenario of a patient through the anaesthetic role of their surgical procedure. It will include and discuss the anaesthetic safety procedures equipment and drug interventions used to ensure this particular patients maximum safety and comfort before and during the procedure. The case study will include pre and peri-operative assessment in order to describe the involvement contribution of various specialties in the holistic care of the critical care patient. This assignment will focus only on the anaesthetics side of the procedure but will also highlight the importance of the triad of anaesthesia and discuss the administration, maintenance and reversal of

VASNHS Surgical Specialty Outpatient department has a designated pre-operative management unit that oversees the patients undergoing surgery. The predicaments stem from various guidelines or protocol originating from numerous surgeons and clinics. At present, the pre-operative nurses abide simple pre-op instructions (NPO protocol, medications, what to bring, during the surgery, transportation, cancellation instructions) for the entire Surgical Specialty Outpatient department. Surgical procedures are being canceled due to lack of communications and cancelations of patients prior to surgery date.

Transmission Control Protocol/Internet Protocol (TCP/IP) are the basic communication protocols, which were designed to provide low level support for internetworking. This term is generally also used to refer to a more generalised collection of protocols developed by the internet community and U.S. Department of Defence.

Lastly, in the surgery theatre, misidentification may happen due to the same factors formerly mention plus failure to mark site/side of surgery, failure to properly perform time-out, and multiple surgical teams (Chan et al., 2010). To analyze the risk for these errors, few factors will be analyzed including human factors (staffing, scheduling, supervision, and qualification), equipment and technology (scanners, computers, and software), Communication (between staff and patients, between staff, between staff and physician, between physician and patient, and between units), environmental factors (physical, safety, security, and preparedness), and procedures and policies (planning, staff education, patient education, protocols, patient identification, and patient observation) (Chan et al., 2010).

A focused audit will be done on all patients undergoing operative or invasive procedures for the next year. Results will be analyzed by the nurse manager and discussed at staff meetings. Evaluation of compliance will be done at the staff meetings and any recommendations for improvement will be discussed and approved at these meetings. Implementation of any recommendations will be instituted the following month. Summaries of the audit and any recommendations for improvement will be sent to the PI committee on a quarterly basis.

In order for physicians to get clinical surgery privileges to perform certain procedures in the realm of their practices, they have to obtain adequate abilities and experiences. There must be a combination of knowledge in theory and experience earned during practical situations. Without a clear confirmation of such combination of theory and practical knowledge, physicians are not in a safe position to perform any procedures. In the hospital setting, physicians must receive the clinical surgery privileges from hospital to perform any procedure there. It is incumbent to hospital to make sure all due diligence is followed by the physician. The hospital must check and cross

At least half a million deaths per year could be prevented with effective implementation of systemic improvements in operating rooms. Specifically, multiple studies have found implementing the use of the WHO Surgical Safety Checklist would significantly reduce surgical morbidity and mortality due to surgical errors.

Wrong site surgery remains the most frequently reported sentinel event, with 908 wrong site surgeries reported since 1995 (AORN, 2010). During the late 1990’s and early 2000’s there was a tremendous public concern and lack of trust for the medical profession, especially within surgical services. We as healthcare professionals needed to step up to the plate, slow down, and take responsibility to improve the quality of care we provide for our patients. Although there still is some resistance from surgeons and other healthcare professionals, overall there has been a general acceptance to universal protocol.

The Joint Commission Board of Commissioners approved the Universal Protocol for preventing wrong site, wrong procedure, and wrong person surgery in July 2003, and it became effective July 1, 2004, for all hospitals, urgent and ambulatory care, and office based surgery facilities. This Protocol was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery and other procedures in Joint Commission accredited organizations. The three principal components of the Universal Protocol, this are a pre procedure verification, site marking, and a time out.