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CS80
Time Out- You're Safe! Implementing the Universal Protocol
By Charlene Cink, RN, CCRN, MS, CNA, BC, & Penny Huddleston, Baylor University Medical Center, Dallas, TX
For further information, please contact: PennyHu@BaylorHealth.edu
Purpose: In July 2003, the Joint Commission (JCAHO) approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery and required all accredited facilities to be in compliance by July 1, 2004. Our challenge was to develop an educational plan for every member of the health care team so they could effectively implement this national patient safety goal. Given our number of staff memebers, this undertaking was enormous. Because it involved so many individuals, we needed to insure that our messages were consistent and processes standardized.
Description: Using available references, we identified the purpose of the Universal Protocol and defined its content. The existing Surgical Site Verification policy was updated to reflect the new "Time Out/Universal Protocol" requirements. We insured processes were standardized across departments and also included bedside procedures outside of the O.R. Practioners document these safety measures on a special multi-disciplinary progress record titled "Time Out/ Universal Protocol for Procedures". Our on-going staff awareness and education campaign focused on "Time Out" posters hung in clinical units throughout the medical center. Staff could easily identify these by their large red Stop signs. Content included procedure settings outside of O.R., inclusion and exclusion procedures, site marking requirements, documentation, and most importantly the specific active Time Out communication that must take place prior to the start of the procedure.
Evaluation/Outcomes: During the JCAHO accreditation visit in late summer 2004, the surveyors asked the health care team many questions about this important patient safety goal. Our staff demonstrated knowledge of these processes and consistent practices hospital-wide. Through these efforts we have created a safer patient care environment contirbuted to optimal patient outcomes.
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