Bedside Procedures SAFE SITE Roadmap SAFE Components 1a) A champion for bedside procedures has been identified for SAFE SITE. 1b) The facility has defined roles, set expectations and provides support for the champion(s). 1c) Individual team member roles in the pre-procedure verification and Time Out process are clearly defined and documented for all invasive bedside procedures. 1d) The facility sets clear expectations that a Time Out must include the person performing the procedure AND one other healthcare provider trained in the Time Out process. 1e) The facility has a designated coordinator to oversee SAFE SITE implementation which includes implementation in department(s) performing invasive bedside procedures (e.g. schedule team meetings, plan staff education). 1f) The facility has a process in place for documentation of the completion of the pre-procedure verification and Time Out process for invasive bedside procedures.
1g) The facility has a process in place to audit the completion of the pre-procedure verification and Time Out process for invasive bedside procedures through chart audits. 1h) The facility has a process in place to audit the effective completion of the specific pre-procedure verification and Time Out process steps for invasive bedside procedures through observational audits. 1i) The facility has a process is in place to review and analyze invasive bedside procedure SAFE SITE data on a regular basis for learnings and improvement opportunities. 1j) Data is shared within and across teams on a regular basis. 1k) Senior Leadership has set clear expectations for effective completion of the pre-procedure verifications and the 5 steps of the Time Out process prior to any invasive bedside procedure. 1l) The facility has a standardized process for conducting pre-procedure verifications for all invasive bedside procedures prior to final positioning/prep (if patient is being sedated for the procedure, occurs prior to sedation) that includes: a) Patient identification with 2 identifiers b) Site marking, if applicable c) Informed consent reviewed with patient and signed by person performing the procedure.
1m) The facility has a process in place to institute a Level I Hard Stop for invasive beside procedures (final positioning/prep does not occur and patient is not sedated, if applicable) if: The site has not been signed, if appropriate The informed consent and verification process has not been completed and reconciled. 1n) The facility has a process in place to institute a Level II Hard Stop for invasive bedside procedures (staff do not complete any additional steps to begin the procedure) if the 5 steps of the Time Out process have not been conducted. 1o) The facility has a clearly defined process for speaking up and stopping the line if a potential safety issue has been identified by staff. The process clearly outlines: When to stop the line; How to stop the line, e.g. I need clarity ; The chain of command to follow if not supported in stopping the line; Clear communication to staff from managers and leadership that staff will be supported if they speak up. 1p) The facility has developed and conveyed clear expectations regarding appropriate behaviors related to the safe surgery/ procedure process. 1q) The facility has a process to review situations in which behavioral expectations are not met in order to
identify system issues vs. at-risk or reckless behavior. 1r) SAFE SITE expectations and supporting education have been incorporated into new employee orientation for all bedside staff involved in invasive procedures. 1s) Ongoing SAFE SITE education for staff is provided at least annually. SITE Components 2a) The facility requires that the person performing an invasive bedside procedure mark the procedure site, as applicable, if the person performing the procedure is not in continuous attendance from the time of the consent through conducting the procedure. 2b) For invasive bedside procedures the facility requires that the 5 steps of the Time Out process are conducted just prior to procedure start: 1- The person performing the procedure initiates the Time Out (calls the team together). 2- All other activity ceases. 3- Designated staff, i.e. nurse, tech, other than the person performing the procedure, verifies patient identity with 2 identifiers (involves patient if able to participate) and verbally reads patient name, procedure and procedure site from the informed consent that has been previously verified. 4- Designated staff, i.e. nurse, tech, other than the person performing the procedure, locates and
verbally confirms visualization of the site mark, if applicable, and states where it is located. 5- performing the procedure states procedure including side/site from memory. 2c) The 5 steps of the Time Out process were performed for invasive bedside procedures 100% of the time this past quarter as indicated by observational audits. 2d) If audit results are below 100%, a plan is in place to address issues identified.