Nursing Education Instructional Guide Understand the Joint Commission s Universal Protocol : Keeping Patients Safe from Wrong-site Surgery Target Audience Patient safety officers Accreditation professionals Quality improvement professionals Risk manager Chief of surgery Medical residency OR director OR circulating nurses Statement of Need This 20-minute training video will provide strategies on properly performing the standards of The Joint Commission s Universal Protocol. It will teach the audience what the actual standards are (preprocedure verification process, site marking, and time out) as well as the best ways to comply with each patient safety standard. (This activity is intended for individual use only.) Educational Objectives Upon completion of this activity, participants should be able to Define the Universal Protocol standard. Describe the intent of Universal Protocol. Recall the Universal Protocol s three main components. Define the pre-procedure verification process. Indicate understanding that a checklist should be used in Universal Protocol. Indicate understanding that the patient should be involved in the pre-procedure verification process. Recognize that a patient s identification, procedure and site need to be verified at many key points. Recognize who is responsible for marking the site.
2 Nursing Education Instructional Guide Recall how the site should be marked. Define a time out. Recognize that a time out must involve verbal interaction. Select the correct process of a time out. Recognize that a time out requires physical and mental focus. Recall the role of the individual leading a time out and recognize that this person must allow for questions to be asked and problems to be resolved. Recognize that a checklist should be used during a time out. Faculty Gloria Legere, RN, MS, JD, is a consultant at The Greeley Company, a division of HCPro, Inc. She has more than 15 years of nursing, consulting, and education experience, with an emphasis on accreditation and regulatory compliance assessment. Legere works with clients on implementing continuous readiness programs; improving work-flow redesign, conformance measurement, clinical operations processes and systems; and installing proven patient safety measures and evidenced-based best practices. (Reviewer): Bud Pate, REHS, is vice president for content and development for The Greeley Company; a division of HCPro, Inc. Prior to joining The Greeley Company, Pate spent fifteen years with system wide hospital quality and compliance responsibility for Kaiser Permanente in Southern California. Before that, Pate worked for the government, where he was responsible for all acute care licensing and CMS certification activities in Los Angeles County. Continuing Education National Association for Healthcare Quality (NAHQ) This activity has been approved by the National Association of Healthcare Quality for 1 CPHQ CE credit. Nursing Education (ANCC) HCPro, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation. This educational activity for 1 nursing contact hour is provided by HCPro, Inc.
Nursing Education Instructional Guide 3 Faculty Disclosure Statement HCPro, Inc., has confirmed that none of the faculty or contributors have any relevant financial relationships to disclose related to the content of this educational activity. Instructions In order to be eligible to receive your nursing contact hour for this activity, you are required to do the following: 1. Watch the video Understand The Joint Commission s Universal Protocol : Keeping Patients Safe from Wrong-site Surgery 2. Complete the exam and receive a passing score of 80% 3. Complete the evaluation 4. Provide your contact information located on the exam and evaluation 5. If you are submitting a group of exams for your staff, please include a typed list of the names of all participants included as well as contact information for the primary contact at your facility. 5. Submit exam and evaluation to HCPro, Inc. Please provide all of the information requested above and mail or fax your completed exam, program evaluation, and contact information to: HCPro, Inc. Attention: Continuing Education Manager P.O. Box 1168 Marblehead, MA 01945 Fax: 781/639-2982 If you have any questions, please contact customer service at 877/727-1728.
4 Nursing Education Instructional Guide Continuing Education Exam Name: Title: Facility name: Address: Address: City: State: ZIP: Phone number: Fax number: E-mail: License number: Date completed: 1. What is The Joint Commission s Universal Protocol? a. A set of standards that ensure patients rate hospitals favorably b. A set of standards to ensure safe surgical practices c. A set of standards used only for surgeries that require site-marking d. A standard requiring proper infection control in inpatient rooms 2. What is the intent of the Universal Protocol? a. To ensure proper infection control procedures are performed b. To provide anesthesiologists guidelines on proper sedation technique c. To provide guidelines that help prevent patient falls d. To prevent wrong-patient, wrong-site, and wrong-procedure surgery 3. What are the three main components (or steps) of the Universal Protocol? a. Pre-procedure verification process, site marking, and timeout b. Site marking, time out and handwashing c. Pre-procedure verification process, time out, and documentation d. Simulation training, site marking, and time out 4. What is a pre-procedure verification process? a. A process in which the surgeon marks the site of the patient b. A process in which patient identification and all critical information is verified prior to surgery and prior to entering the operating room or place of procedure c. A process that takes place in the operating room in which every member of the surgical team identifies themselves immediately prior to surgery d. A process that defines how to properly greet a patient at admission
Nursing Education Instructional Guide 5 5. A should be used during the pre-procedure verification process, according to Universal Protocol. a. mirror b. marker c. checklist d. time out 6. If possible, should be involved in the pre-procedure process. a. a computer b. site marking c. a time out d. the patient 7. When do the patient s identification, procedure, and site need to be verified? a. Only at the patient s admission and prior to the patient s surgery b. Only when care of the patient is transferred and right before surgery c. Only when the patient is under anesthesia d. When the procedure is scheduled, during preadmission testing and assessment, at the time of admission, whenever care is transferred, and before surgery as part of the pre-procedure process 8. Who should mark the site? a. Whoever is available and has the patient s current records. b. A surgeon or licensed independent practitioner involved in the surgery. c. Any physician can mark the site. d. It should always be the circulating nurse. 9. Which option below is the way The Joint Commission recommends marking the site? a. However the patient would like it to be marked. b. The site does not ever need to be marked. c. With the site marker s initials, or according to your hospital policy. d. With an x. 10. What is a time out? a. It is the time when the patient is put under anesthesia. b. It is when the surgeon marks the site. c. It is a period of time post-surgery in which the team verifies that everything went correctly and as planned. d. It is a period of time directly prior to surgery in which the entire operative team pauses to ensure everything is correct before surgery begins.
6 Nursing Education Instructional Guide 11. During a time out, the operative team must participate in active communication. a. quiet b. loud c. complex d. verbal 12. What should occur during a time out? a. The circulating nurse should verify all documentation. b. All non-essential activities are stopped, and the entire operative team participates in active verbal communication to verify critical elements of the procedure. c. All members of the operative team except the surgeon should verify information. The information should then be relayed to the surgeon as necessary. d. The site should be marked. 13. During the time out, each member of the operative team must: a. conduct a moment of silence b. be present, physically and mentally c. count instruments and scrub up d. mark the site 14. The person leading a time out should: a. be the only one to talk during the entire time out process b. mark the site c. allow for questions to be asked and conflicts to be resolved d. fill in for the surgeon if he or she is not present 15. According to The Joint Commission, the time out should be conducted using a: a. checklist b. microphone c. washable marker d. mnemonic device
Nursing Education Instructional Guide 7 Continuing Education Exam Answer Key (Please record all exam and evaluation answers here.) Name: License #: Facility: Title: Address: City: State: ZIP: Phone: E-mail: (Certificates are e-mailed to learners unless otherwise stated here.) Please record the letter of the correct answer to the corresponding exam question below. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Continuing Education Evaluation 1 = Strongly disagree 2 = Agree 3 = Disagree 4 = Strongly agree (Please rate the responses below to evaluate the quality of this educational activity.) 1. Please indicate how well you feel this activity met the learning objectives listed. 2. Objectives were related to the overall purpose/goal of the activity. 3. This activity was related to my continuing education needs. 4. The exam for the activity was an accurate test of the knowledge gained. 5. The activity avoided commercial bias or influence. 6. This activity met my expectations. 7. The format was an appropriate method for delivery of the content for this activity. 8. Will this activity enhance your professional practice? Yes No 9. How much time did it take for you to complete this activity? 10. Do you have any additional comments on this activity? Return completed form to: HCPro, Inc. Attention: Continuing Education Manager P.O. Box 1168, Marblehead, MA 01945 Telephone: 877/727-1728 Fax: 781/639-2982