Minnesota Hospital Association

Quality & Patient Safety

April 11, 2008

Minnesota Patient Safety Alert: Incorrect Information in Source Document Used to Verify Procedures


Minnesota Hospital Association (MHA) and the Minnesota Department of Health (MDH) have reviewed data from the adverse health event reporting system and have noted a cluster of wrong invasive procedures that have resulted from failure to identify incorrect information in source documents used in pre-operative verification.


MHA and MDH recommend that facilities revisit the source documents and verification procedures that are used to schedule procedures, complete informed consent documents, and perform pre-operative verification. While research is inconclusive regarding best practices for use of source documents and verification, the following suggestions should be considered in developing processes within your organization:

  • Discussions with local and national experts have suggested facilities consider “5 Rights of Verification” — the procedure to be performed is verified against:   
  • Provider’s surgical/procedure order; 
  • Radiology and pathology reports — if relevant to procedure; 
  • Informed consent documentation; o Patient’s understanding of the procedure to be performed;   
  • Diagnostic imaging (properly labeled, displayed and viewed along with the radiologist’s report).
  • There are other documents that could be included in this list of source documents such as the provider’s pre-procedure note.
  • If there is a discrepancy in any of the source documents, the history and physical diagnosis and plan can be utilized to help in the reconciliation process.
  • While efforts should be made to improve the accuracy of the operating room/procedure room schedule, the schedule should not be used as a source for verification of patient or procedure.
  • Analysis performed by David Marx, Outcome Engineering LLC, estimates that assigning one person to perform verification using a single source document, e.g. the informed consent document, results in a failure rate of 1 in 1,000 procedures. Adding a second person to perform an independent verification using two source documents, e.g. surgical order and history and physical, decreases the failure rate to 1 in 100,000 procedures. A third independent verification using three source documents decreases the failure rate to 1 in 1 million.
  • Independent documents should be used wherever possible rather than using one source document that is also the basis for subsequent documents. Relying on dependent sources of information could allow for an error to be carried through the process.
  • A pre-procedure checklist detailing the verification of multiple source documents by independent reviewers should be completed prior to any invasive procedure. The procedure should not proceed until the checklist is complete and reconciled.
  • The organization’s policy and checklists related to pre-procedure verification should include a clear description of who is responsible for verifying the procedure against each of the sources of information, along with a clear process and assignment of responsibility for reconciling discrepancies among any of the information sources prior to the procedure.
  • The policy should require not only that relevant imaging be available prior to the procedure, but also that it be viewed, along with the radiologist’s report, as part of the pre-procedure verification process.

For more information on the Patient Safety Registry, adverse health event reporting or this alert, contact Julie Apold, MHA director of patient safety, at japold@mnhospitals.org or (651) 641-1121 or toll-free at (800) 462-5393

Sunday, October 8, 2023 5:39 PM

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