As you use the Multimedia Procedure Manual, you will notice that preparation is a recurring theme that receives a great deal emphasis. In additon to prepartory steps specific for each individual procedure, there are numerous topics that should be considered a priori in ALL medical procedures. This section will begin to explain some of these key universal principles.

CHOOSING THE RIGHT PROCEDURE

A successful procedure begins with the planning phase. The first step is to choose the procedure that meets the medical objectives while minimizing risk, discomfort, and expense for the patient. In many cases, there will be limited options – e.g. if a lumbar puncture is indicated to detect subarachnoid hemorrhage, there are no alternative procedures available. But in other cases, such as the care of a laceration, there might be several options to choose from. The decision about which procedure will be performed is ultimately the patient’s. The physician should provide a thorough explanation of the medical condition, the available procedures, and the risks and benefits of each. Please refer to the Consent section of this chapter for further details about informed consent.

 

To choose the procedure(s) that will be recommended to the patient, the physician needs to spend time understanding their objectives and gathering data about the patient:

 

 

The key point to remember is that it is ultimately the patient's choice, and the physician's goal is to provide enough basic knowledge about the alternatives that the patient can make an informed decision.

PRE-PROCEDURE PLANNING

Successfully performing a procedure is a complex activity that requires integration of both motor and cognitive processes[4, 5], and requires a large number of critical steps. In this sense, performing a medical procedure is analogous to flying an airplane. In the airline industry, pilots and crew use pre-flight briefings and checklists to reduce errors and prevent crashes. A similar stepwise approach to planning has been suggested for medical procedures, mainly in the context of teaching procedures to medical students[5, 6].

 

The first step is to review the indications, contraindications, materials, technique, and potential complications of the procedure[6]. Reviewing these details is essential, because they will later be conveyed to the patient during the process of informed consent.

Next, the procedure should be broken down into basic steps and mentally reviewed. This allows the physician to enhance learning (and chance of success)[7-9] as well as to develop a checklist of the required equipment[3].

 

 

Error reduction

The Universal Protocol | Patient Identification

It has been estimated that between 44,000 and 98,000 people die in hospitals each year as a result of preventable medical errors. [Refer to To Err is Human: Building a Safer Health System, an online publication from the Institute of Medicine, for further details.] A great deal of work is being done to understand the system failures that lead to these medication, laboratory, and procedure-related errors.

In an effort to reduce such errors, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has issued a set of 7 National Patient Safety Goals for 2004. These goals consist of 13 specific regulations that cover a wide range of patient safety issues, among them patient identification, improving provider communication, and prevention of side/site errors.

The Universal Protocol

In addition to the Patient Safety Goals, JCAHO has developed and promulgated the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. While this protocol is most applicable to surgical procedures performed in the operating room, it is also relevant to procedures performed in the emergency department that involve left/right distinction, such as thoracentesis, tube thoracostomy, and arthrocentesis. The protocol is based upon the following principles:

    

  • Active involvement and communication between all team members is important for success
  • The patient should be involved whenever possible
  • A standardized, yet flexible, approach to this protocol should be adapted in order to provide consistent implementation
  • Site marking should be employed for procedures requiring left/right distinction

 

As demonstrated in the video, the following three steps should be followed:

 

  • Pre-procedure verification process. All information, documents, and studies must be available and reviewed prior to the start of the procedure. This process begins at the time of determination to do the procedure and continues up to the "time out" immediately before the procedure is done.
  • Mark the correct site. Procedures involving left/right distinction, multiple structures (e.g. digits or joints), or levels (e.g. spinal procedures), the intended site must be marked, and that marking must be visible after the patient has been draped.
  • Time out. A final verification of the correct patient, procedure, and site immediately prior to execution of the procedure.

 

For more information, please visit the JCAHO website.

 
Patient Identification
Current JCAHO regulations require that two separate patient identifiers (neither being the room number) be used to identify the correct patient when taking blood samples or administering medications or blood products. These identifiers should be matched to identifiers on medications, lab requisitions, blood products, and any other documentation that accompanies medical care. When possible, the patient should be actively involved in this process, for example by asking the patient to state his name.
 

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