mented its
Universal
Protocol
designed to elimi-
nate — or at least
vastly reduce —
never events. But
improvement has
been slow and
disappointing,
say experts.
A recent Outpatient Surgery Magazine survey of more than 550
readers may shed some light as to why. We asked about one of the 3
key components of the protocol — site marking. The response was
eye-opening and maybe a little disconcerting. Specificity, standardiza-
tion and 100% compliance are the protocol's intended pillars, but in
practice, many providers appear to be viewing its provisions as sug-
gestions, not edicts.
For example, we asked: "Are your marking methods and marks stan-
dardized for all cases?" They aren't, 15% of our respondents admit. We
asked: "What type of mark do you use to identify surgical sites?" The
results were mixed: 56% say the surgeon initials the site and 10% say
whoever's doing the marking (more on that later) writes the word YES.
Those answers are the only 2 universally accepted practices. Rather
than representing the proposed incision with an unambiguous site mark-
ing of the surgeon's initials or YES, many surgical facilities may still be
using X's, dots, lines, arrows, smiley faces or whatever else comes to
mind.
"Variability in the marking process leads to ambiguity for the surgi-
cal team and risk for the patient," says patient safety expert Spence
4 5
J U LY 2 0 1 5 | O U T P A T I E N TS U R G E R Y. N E T
Pamela
Bevelhymer,
RN,
BSN
z WHO'S IN CHARGE? If anyone other than the sur-
geon does the marking, you may be asking for trouble.
