Site Verification: Meeting National Patient Safety Goals

Many hospitals across the country are in the process of writing policies and changing procedures to comply with National Patient Safety Goals that are relevant to the services that the organization provides. JCAHO expects these organizations to have implemented all of the recommendations by January 1, 2003. Five months after the expected implementation date, many cath labs are debating whether they fall under all of these standards. The six National Patient Safety Goals are: 1. Patient Identification 2. Communication 3. High-Alert Medication 4. Wrong-Site Surgery 5. Infusion Pumps 6. Alarm Systems Some of the National Patient Safety Goals are easy to understand in relation to the cath lab environment. Other goals have left some of the most veteran cath lab managers shaking their heads in disbelief. The goal generating the most discussion is Wrong-Site Surgery. Everyone understands the importance of marking the correct leg on a diabetic patient headed to surgery for a leg amputation. Here, an effort needs to be made to ensure that only the bad leg is removed and the leg removed is on the correct patient. Under debate has been the need to mark the cath entry site indicated by the physician and the steps necessary to make sure the correct site is marked and used. The JCAHO website answered some questions but not clearly enough to eliminate the debate. The website does indicate that the goals apply to all invasive procedures that expose patients to more than minimal risk, including those done in an interventional radiology suite. JCAHO also notes that routine or minor procedures, such as venipuncture or peripheral IV line placement, are not within the scope of this goal. Across the country, many labs report being cited by JCAHO during inspections of their institutions. In many cases, the inspectors are specifically requesting to see what the cath lab is doing in regards to site verification. Specific questioning on site verification in the cath lab by Cath Lab Digest led to JCAHO’s response on page 40 (from Dr. Richard Croteau, Executive Director for Strategic Initiatives), which clearly indicates that cardiac catheterization labs should be marking cath access sites. Cited hospitals argued whether marking a cath access site was truly necessary, noting that there was no reason the physician could not use an alternative site. During one inspection, however, the JCAHO inspector stated that if there were a contraindication to using a site it would have been identified in this process. JCAHO has also indicated that the practice of marking an X or NO on contraindicated access sites is not acceptable. JCAHO has indicated that the main reason for site verification is to avoid doing the procedure on the wrong patient. The policy and procedures used by the cath lab should be based on the National Patient Safety Goals. This begins with the patient consent form. It should indicate: Procedure Site, including laterality if appropriate; Patient Name; Reason for Procedure; Name of Procedure. This step provides for increased safety. The patient or his/her representative has the opportunity to identify a mistake before the he or she is on the table and ready for catheterization. Second, the site must be marked before the patient arrives in the cath lab. This eliminates the hurried atmosphere that sometimes exists in the cath lab. The policy could include a statement addressing what will be done in emergency or life-threatening situations when it may be inappropriate. JCAHO allows for an exception when the practitioner performing the procedure is in continuous attendance with the patient from time of the consent through to the actual performance of the procedure. A physician or other privileged provider who is a member of the cardiac cath patient care team should mark the site. This should be done with the involvement of the patient. However, the patient should not be the one marking the site. As stated earlier, to prevent confusion, non-access sites must not be marked. An X to one person marks the spot; to another, it means no. The practice in one institution is to mark an X along with the initials of the cardiologist performing the procedure on an identified access site. The next step is Patient Identification. This is done prior to the patient entering the cath lab. Ask the patient his/her name rather than asking for confirmation of his/her name. This avoids a hard of hearing or confused individual from incorrectly answering yes to a misunderstood question. Continue the patient identification by asking and confirming the patient’s birthdate or full social security number. Finally, ask the patient to state where he or she understands the access for the procedure will be made. In the cath lab, two members of the cath team must check imaging data, if being used in the case, to confirm a site. This relates more to surgical procedures than to completing a cardiac catheterization. The confirmation makes more sense if peripheral studies are done in your lab and access into a particular artery would be contraindicated, as indicated by the previously taken images. The last step required is a Time Out. The personnel in the cath lab must take a moment to verify, one last time and when the patient is present in the lab, that they have the correct patient, site and procedure. As always, document what you do in policies and via an appropriate site verification checklist. As these patient safety rules extend beyond the cath lab, it may be appropriate to write policies and develop practices that cover the entire institution. (i.e., the operating room, cath lab and diagnostic imaging). The procedures and forms used by each organization will then be customized to meet the organization’s needs, and the end result is everyone in your institution will be following the National Patient Safety Goals. Michael Wellner can be reached at MWellner@hfmhealth.org

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