MHA has reviewed data
from hospitals that have agreed to share adverse health event reporting information
and has noted a cluster of wrong body
part events related to chest procedures.
Review of these events shows
that these invasive
procedures were performed
outside the operating room (e.g.
patient’s room, radiology department) and a “Time Out/Pause for the
Cause” (pause and verification
just prior to the incision or
injection) was not conducted.
Safest in America “Safe Site Protocol for Invasive and Surgical Procedures” (available at http://www.mnhospitals.org/inc/data/pdfs/SIA_ISCI_protocol.pdf) recommends pause and verification for all invasive
procedures which should take place in the location where the procedure will be done.
This protocol is not limited
to the operating room.
MHA recommends that all hospitals review their policies for invasive procedures
performed outside of the operating
It is also recommended that
hospitals have a system in place to check if
pause and verification is taking place in these settings
(in some instances it was thought
that the process was taking place but there was confusion as to which settings
the pause and verification process applied).
Some Minnesota hospitals are developing a process in which a pause and verification
checklist is automatically printed
with each informed consent document and are standardizing their protocols
and forms across their organizations.