Patient Identification - Correct Patient, Correct Procedure and Correct Site

This policy has been widely implemented within NSW Health agencies.  As at March 2011 it is under review to include implementation of Surgical Safety Checklist requirements. 

In recent years, professional associations such as the Royal Australasian College of Surgeons and jurisdictions such as state health departments have recognised this safety and quality priority. Further, the Word Health Organisation (WHO) has undertaken a number of global and regional initiatives to address surgical safety.  One of these initiatives is the Surgical Safety Checklist.  The Checklist aims to address important safety issues in the operating theatre including patient identification, correct site surgery, retained surgical iems, anaesthetic safety practices, avoidable surgical infection and communication among team members.

In 2009 health ministers across Australia endorsed the WHO Surgical Safety Checklist and agreed it would be implemented nation-wide 1 July 2011. Using the Checklist provides a means of verifying that critical safety aspects of care have been performed and are communicated to all membes of the surgical team in a systematic way. In doing so, the Checklist increases the reliability of key clinical processes and assists operating theatre teams to plan for variations in expected care.

As well as making surgery safer, the Checklist is designed to improve teamwork and communication and, as a result, provide a safer and more effective working environment.

The NSW Health Correct Patient, Correct Procedure and Correct Site policy directive is clear that the responsibility for ensuring identification of the correct patient, correct procedure and correct site rests with all members of the health care team.  The mandatory policy directive applies to all health care facilities where procedures are undertaken and has application beyond operating theatres alone. It includes all procedural areas for intended invasive or diagnostic procedures: endoscopy, dentistry, radiology, nuclear medicine, chemotherapy and radiation therapy, wards, emergency departments, intensive care and all other procedural areas.

A HNE Health Correct Patient, Correct Procedure, Correct Site / Patient Identification Reference Group monitors and reviews practices, makes informed decisions relating to policy and takes responsibility for implementation issues arising from PD2007_079. The Reference Group ensures decisions regarding improvement can be acted upon by the relevant Directors in a timely manner. Implementation of their recommendations is undertaken jointly with the Executive Directors responsible for clinical operations and Director Clinical Governance through the HNE Health Clinical Quality Safety Commiittee.

To date the Reference Group has had a primary focus on implementing “Time Out” in operating theatres, imaging and oral health services. However, anecdotal reports do indicate that while time out in theatre is being documented as complete it may not have been completed as per policy requirements e.g. whole team may not have participated and some steps may have been short-cut. These reports have been validated through recent Root Cause Analysis findings of non-participation of whole team and lack of clarity around who constitutes the membership of the team.

Should you have any questions concerning the rollout, implementation or auditing required of this Policy Directive please contact either:

• Dr John Fisher, Associate Director Clinical Governance on Ph: 6767 8881 
• Ms Anne Barry, Clinical Audit Manager, Clinical Governance on telephone 4921 4168

 
Useful Links

• NSW Health PD2007_079 Correct Patient, Correct Procedure and Correct Site
• New England Journal of Medicine -- A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population