1. Effective Handoff Communication, Part 2:
Standardizing Processes Throughout Your Organization
CONTENTS
Effective Handoff
Communication, Part 2:
Standardizing Processes
Throughout Your Organization 1
Patient Safety Pulse
Your Patient Safety News
The Joint Commission Center
for Transforming Healthcare
Unveils Targeted Solutions
Tool 2
Moving Your Hospital to a New
Facility, Part 2:
Patient Safety on the Move 6
Alternative Surgical Site Marking:
Compliance Strategies for the
Joint Commission Universal
Protocol for Preventing Wrong
Site, Wrong Procedure, Wrong
Person Surgery 9
Handoffs should occur in a space where staff are unlikely to be interrupted.
Standardizing handoff communications
throughout an entire organization is a
daunting and elusive challenge for health
care organizations. Indeed, Wall Street
Journal health columnist Laura Landro
once referred to patient handoffs as “The
Bermuda Triangle of health care.”1
Nevertheless, health care organizations
have an obligation to take up this chal-lenge
for the sake of their patients.
Ineffective handoff communications
put patients at the following direct risks2:
• Medication errors
• Surgical errors
• Violations of do-not-resuscitate
orders
• Delays in treatment
• Incorrect diagnoses
• Longer hospital stays
• Other health problems
A malpractice insurance provider that
serves the Harvard medical community,
reports that handoff-related cases represent
www.jcrinc.com
The Joint Commission
Perspectives
on Patient Safety TM
November 2010 Volume 10 Issue 11
(continued on page 3)
By Michael S. Woods, M.D., M.M.M.
3. Effective Handoff Communication, Part 2
(continued from page 1)
losses of more than $173 million for its
clients during a five-year period. Nearly
400 physicians and more than 70
nurses in health care organizations
insured by the insurance provider have
been named in 268 claims and suits
with a handoff-related complaint, more
than half of which involve patient
injuries of high-severity.3
This is the second of two articles
that address safe and effective handoff
communications. The first article,
which appeared in the October 2010
issue of Perspectives on Patient Safety,
discussed the risks associated with
patient handoffs, and a tool developed
for implementing the SBAR technique
for handoffs.* This article discusses
strategies for organization-wide stan-dard-
ization of handoff processes.
The Importance of
Standardization
Experts and patient safety advocates
have called for standardization of hand-off
processes as a means to improve
handoff communications. Also, Joint
Commission standards require organiza-tions
to follow a standardized handoff
process. However, organizations continue
to struggle to meet this goal. Despite the
appearance of simplicity, very few organ-izations
have been able to implement
systemwide standardization. Success
requires the close coordination of
numerous stakeholders within the
organization to do do the following:
• Develop and implement the
process
• Allocate resources
• Obtain leadership and staff
buy-in
• Train personnel
• Evaluate performance
Put simply, standardizing handoff
processes requires a large-scale cultural
change.
Hierarchical relationships among
staff can hinder effective communica-tion,
including handoffs. Status
differences can discourage team mem-bers
perceived as juniors or subordinates
from speaking up, pointing out discrep-ancies
or potential errors, or even from
asking questions. Research from other
industries illustrates this dynamic.
Airplane cockpit communication has
been shown to be deficient between
persons who are unequal in status, such
as between the captain and the flight
engineer. This problem may be even
more prevalent in health care than in
other industries due to the rigid hierar-chies
that have existed for nearly a
century and have become deeply
embedded in the industry’s culture.
In a survey of 1,033 health care work-ers,
from intensive care units and
operating theaters, and more than
30,000 cockpit crew members, 70% of
the total respondents said that it was
appropriate for a junior team member to
question senior staff. However, the
respondents differed depending on posi-tion
and discipline. Only 55% of
consultant surgeons said they would sup-port
a flat hierarchy versus 94% of
cockpit crew members and intensive care
staff.4 The previous success of creating an
environment in which all members of
the team have an equal voice is essential,
yet support for creating such an environ-ment
by the very group who would
likely benefit, based upon this study, is
minimally better than a coin toss.
Also, the standardized protocol must
be tailored to meet the needs of differ-ent
disciplines and organizations. Many
disciplines have unique needs, so there
must be recognition of those aspects of
the process that may or may not be
able to be generalized. The process
must be tailored to meet the needs of
the end user.5
What Does Standardization
Look Like?
A standardized process should include
a means to educate staff about the
process and a plan for organizationwide
implementation. The standardized
process should also inlcude a list of
handoff situations that occur within
the organization for example, a patient
moving from the ER to the medical-surgical
inpatient unit, or a patient
moving from the post-anesthesia unit
to the medical-surgical inpatient unit.
Partners HealthCare Systems developed
a list of clinical data that the receiving
clinician requires to provide safe care
during the first 72 hours after transfer.
The list included the following
elements6:
• Focused history
• Focused physical exam
• Pertinent past medical history
• Pre-admission medications
• Allergies
• Medication reactions/drug
intolerances
• All significant critical conditions
• Procedures
• Hospital course
• Pertinent test results
• Future care plans
• Results pending that require
follow-up
• Name/number of discharging
physician and primary care
physician
• Discharge medications with
diagnoses
A list such as this can be customized
to meet your organization’s specific needs.
Whatever the process used, it should be
focused on identifying critical content
that should be transferred during a hand
off.5 Content omissions are a significant
source of communication failure during
(continued on page 4)
* SBAR is an acronym for Situation,
Background, Assessment, and
Recommendation. The U.S. Navy origi-nally
developed SBAR for use on
nuclear submarines. Later, staff at Kaiser
Permanente adapted the process to
apply to hand offs in health care.
www.jcrinc.com THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY November 2010 3
4. Effective Handoff Communication, Part 2
(continued from page 3)
hand offs. It can be helpful to develop a
checklist of necessary information and
incorporate that into the process, and
involve staff in selecting what informa-tion
should be included on the checklist.5
A Top-Down Team Approach
Once you decide to embark on a path
of standardization, the first step is to
gain C-suite support, including, at a
minimum, the CEO, the vice president
of medical affairs/chief medical officer,
and the vice president of nursing (or
equivalent). The likelihood of success
for clinical initiatives, like SBAR, is
maximized by close cooperation
between the medical staff and nursing.
This top-down leadership endorsement
is not just nice to have… it is
absolutely necessary. C-suite leadership
should very clearly communicate its
support (and expectation) that all staff
will participate in the process.
When OSF St. Joseph Medical
Centerin Bloomington, Illinois began
is handoff standardization project, the
chief nursing officer served as executive
director of the team, and a portion of
her compensation was contingent on
meeting implementation goals. Medical
directors were named as sponsors to
champion the use of the process among
medical staff peers. The patient safety
officer was the day-to-day project man-ager
for the team.8 This is an excellent
example of how leadership can support
the process.
Once these alliances have been
formed, the next step is to build a team
that will oversee development and
implementation. The team should
include representatives of all stakehold-ers,
including division chiefs, front line
attendings, fellows, residents, physician
assistants, nurse practitioners, registered
nurses, and other key staff members.9
The team should conduct a needs
assessment. They need to know in what
situations within their organization are
handoffs necessary, how they are cur-rently
being done, what information
needs to be shared during those hand-offs,
and whether that essential
information is actually being shared.6 A
number of methods are available for
conducting this assessment, including
staff surveys, direct observation, and for-mal
techniques such as Failure Mode
and Effects Analysis (FMEA).6 The
team should attempt to craft answers to
the following key questions6:
• What problems exist with the
current handoff process (if any)
and what effect do they have?
• What will happen if no change
occurs?
• Why should action be taken now?
• How will success be measured?
• What will the new processes
require?
• How will things be different if we
make the intended change?
• What is the cost of changing
versus the cost of staying the
same?
It is also helpful for staff to under-stand
the ways in which the changes
will benefit them. For example, stan-dardized
processes can help reduce
unnecessary or duplicate work.2
Some organizations have had success
using pilot programs within individual
departments or groups of departments
and gradually rolling out the program
throughout. OSF St. Joseph Medical
Center initially implemented their stan-dardized
SBAR process in a general
medical nursing unit in 2004; organiza-tionwide
implementation was complete
by the following spring. Among other
activities, OSF St. Joseph started a
“secret shopper program” in which staff
members were called at random and
asked questions about SBAR. Results of
these surveys were shared throughout
the organization. Stickers and posters
reminding staff to use SBAR were posi-tioned
throughout units, and training in
SBAR was included in annual staff edu-cation
programs. For Fiscal Year 2005,
OSF St. Joseph reported a mean of 96%
use of SBAR.9
Brigham and Women’s Hospital in
Boston implemented its handoff process
in phases; beginning by targeting nurse-to-
nurse, resident-to-resident, and
operating room–to–post anesthesia care
unit handoffs. The second phase targeted
Patient Safety Editorial Advisory Board
Bonnie M. Barnard,
M.P.H., C.I.C., Quality
Specialist, St. Peter’s
Hospital, Helena,
Montana
Hedy Cohen, R.N., M.S.,
Vice President, Institute for
Safe Medication Practices
Kathy Connolly, R.N.,
M.S.Ed., C.P.H.R.M.,
Assistant Vice President,
Risk Management, Premier
Insurance Management
Services, Inc.
Nilda Conrad, M.B.A.,
C.P.M.S.M., C.P.C.S.,
President, National
Association of Medical Staff
Services
Diane D. Cousins, R.Ph.,
National Quality Forum’s
Expert Panel
David Fuller, Senior Space
Systems and Operations
Engineer and Associate
Fellow of the American
Institute of Aeronautics and
Astronautics
Suzanne Graham, R.N.,
Ph.D., Director of Patient
Safety, California Regions,
Kaiser Permanente
Robert S. Lagasse, M.D.,
Vice Chairman, Department
of Anesthesiology, Albert
Einstein College of Medicine
& Montefiore Medical
Center, New York
Jeannell M. Mansur, R.Ph.,
Pharm.D., F.A.S.H.P.,
Practice Leader, Medication
Safety, Joint Commission
Resources
David Marx, Head of the
Paediatric Gastroenterology
Team, University Hospital,
Czech Republic
Deborah Nadzam, Ph.D.,
R.N., F.A.A.N., Director,
International Quality and
Performance Measurement,
Joint Commission
Resources
Rita Shane, Pharm.D.,
F.A.S.H.P., Director,
Pharmacy Services, and
Assistant Dean, Clinical
Pharmacy, UCSF School of
Pharmacy, Cedars-Sinai
Medical Center, Los Angeles
Paula Spears, D.N.Sc.,
R.N., Corporate Director,
Professional Practice and
Advancement, Methodist Le
Bonheur Healthcare,
Memphis
Sherry Umhoefer, R.Ph.,
M.B.A., Vice President,
Quality and Compliance,
McKesson Medication
Management
4 THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY November 2010 www.jcrinc.com
5. Table 1: Behavioral Change Process.
Awareness Accountability Follow-up
• Clear understanding of the benefits
of SBAR: Safety, quality outcomes
— Understand the role of
communication in major
safety/quality errors (see sidebar
on page 11)
• Clear understanding of the benefits
of SBAR: Safety, quality outcomes
• Research best practices; learn from
other organizations
• Clear understanding of the benefits
of SBAR: Safety, quality outcomes
• Learn their area-specific SBAR
handoff process
attending-attending, procedural area,
and ambulatory setting handoffs.10 The
organization developed guidelines to
address interdisciplinary problems that
affected handoffs, launched a training
initiative for staff, and created ID badge
inserts describing best practices to
remind staff. Their team evaluated the
process one month and six months after
full implementation and found that the
time to complete a handoff was reduced
by an average of seven minutes, dupli-cate
information had been minimized,
and feedback from frontline providers
was positive.10
Sustaining Positive Change
Organizations that have achieved success
in this area have recognized that in the
end it isn’t just about creating a solu-tion.
The roads of mediocrity are
C-Suite Support
• Clearly communicate support and
expectations in the organization
• Make SBAR/handoffs a corporate
priority and/or quality goal
Development Team
• Identify handoff points in organization
• Clarify special needs by unit
• Design a general process by
identifying common needs from
unit to unit
• Develop metrics to measure success
• Create and implement pilot
• Create rollout timeline for handoff
expansion
End user
• Goal: 95% compliance in using
process
• Conider link to:
— Performance review
— Compensation
littered with unimplemented or unsus-tained
solutions. Rather, the goal is to
sustain positive change based upon the
solution. The success of any patient
safety initiative depends on a commit-ment
from all stakeholders, including
leadership and staff, to build and sustain
a systemwide positive shift to a culture
of safety. Noticeable change is likely to
be gradual. Organizations should intro-duce
staff to new concepts, new ways of
thinking about how they do their jobs,
and should provide the tools they need
to implement these concepts.2
End-user staff is more likely to
embrace change if they are involved in
the decision-making process. The team
approach is helpful in engaging indi-viduals
across the organization in the
development process. Make sure staff is
informed and educated about why the
• SBAR Dashboard: Track
implementation progress; identify
links to safety measures
• Populate executive dashboard with
metrics
• Provide feedback to end users
Clearly communicate successes
• Identify opportunities for
improvement
• Feedback from fellow end users as
to effective use
• Performance review
changes are necessary. But education
alone is not enough. The following
three components should be integrated
in to each step of the development
pathway to a solution:
1. Creating awareness
(education/learning)
2. Developing accountability (both
personal and organizational)
3. Building in routine follow-up to
document meaningful change
For example, Table 1 (above) shows
how these three components are inte-grated
into the implementation of the
SBAR methodology. Organizations
interested in effecting this kind of sus-tained
positive change should foster
learning opportunities for staff, and
encourage staff to adapt to the changing
(continued on page 11)
www.jcrinc.com THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY November 2010 5
6. Moving Your Hospital to a New Facility, Part 2:
Patient Safety on the Move
Northwest Community Hospital ensured that each patient was with a nurse they knew
during the transfer.
Pat Stack, vice president of
Transition Planning, arrived at
Northwest Community Hospital
(NCH), in Arlington Heights, Illinois,
at 3:00 A.M. on Saturday, May 1, 2010.
She and the rest of the staff at NCH
were faced with moving 140 adult
patients plus 6 infants from the Special
Care Nursery to a new facility. They
had to accomplish this in about 4½
hours without any adverse events, med-ication
errors, or delays in patient care.
Similarly, in 2012, staff at the Johns
Hopkins Children’s Center in
Baltimore, Maryland, will be facing the
same goals when they transport pedi-atric
patients to the new Charlotte R.
Bloomberg Children’s Center.
Planning for the safe transport of
patients to new hospital buildings has
become more common, as evidenced
by the 121 new or replacement hospi-tals
completed in 2004, and the
increasing number of consulting busi-nesses
that offer transitional planning
services to growing hospitals.1
For more information on the prepa-ration
that takes place prior to moving
day (such as designing a new hospital
with patient safety and family-centered
care in mind, and teaching staff how to
provide care in the new hospital), see
the first article in this two-part series,
which published in the October 2010
issue of Perspectives on Patient Safety.
Moving Equipment and
Supplies
Organizations may choose to purchase
all new equipment for the new or
replacement building, which is benefi-cial
for the day of the move because
fewer items go on the moving list.
However, moving current equipment
over to the new building can reduce
costs. At Hopkins Children’s, 70% of
the equipment and supplies will be
purchased for the new facility, but 30%
will be reused from the current build-ing.
“It has complicated things a bit by
not buying all new equipment,” says
Michael Iati, senior director of
Architecture and Planning, Johns
Hopkins. “You can’t just close down
the old building and run to the new
building and start taking care of
patients. It’s more complicated to move
equipment in addition to the patients,
and we’ll have to recalibrate equipment
in a leapfrog effect as we move.”
Move equipment
STRATEGY
first. When possible, move equipment
before transporting patients to the
new building to reduce congestion.2
Furthermore, label items to be moved
prior to moving day to reduce confusion.
Involve Patients and Families
More than two years before the planned
move to the Charlotte R. Bloomberg
Children’s Center, staff at Hopkins
Children’s started meeting with family
members to understand any concerns
they might have and solicit their advice
for the move. Involving patients and
family members in any organization
decision is nothing new to Hopkins
Children’s, where a Family Advisory
Council meets monthly and a full-time
parent advisor helps enhance communi-cation
between parents and staff. “The
parent advisor also attends planning
meetings for the new hospital and shares
her insights as a parent as well as the
6 THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY November 2010 www.jcrinc.com
7. opinions of other parents she meets with
on a routine basis,” says Ted Chambers,
pediatrics administrator at Johns
Hopkins Children’s Center.
Deciding how involved family mem-bers
should be on the actual moving day
can be difficult. “On the one hand, if we
have families with us during the move, it
will take longer,” said Stack, “But not
allowing family members the option of
coming didn’t seem fitting with our
overall vision of family-centered care. So
we talked to patients and family mem-bers
on the Thursday before the move,
and gave them an information packet
explaining the move. We said that family
members were welcome to be with the
patient during the move, but noted that
it might be easier if they didn’t come till
the afternoon when the move was over.”
Hopkins Children’s is dealing with how
to handle the same issue. “We’ve had a
lot of discussions with family members
on how to conduct the move with fam-ily,”
says Chambers, “and we’ve come to
the conclusion that it’s better to have one
family representative (for example, a par-ent)
present during transport and have
the rest of the family waiting in the new
facility.”
Keep family mem-bers
STRATEGY
informed on moving day.
Even if family members choose not to
go along with the patient during the
actual transport, organizations can keep
family members involved and
informed. “On the moving day, we set
up a family lounge in the cafeteria with
free breakfast and lunch,” Stack says.
“We also had a computer tracking sys-tem
available so family members knew
exactly when patients had been moved
to the new building and were tucked
safely into bed.” Similarly, Hopkins
Children’s plans to keep the lines of
communication open between family
members and staff during the move.
“We know that the more we communi-cate,
the better things go,” Chambers
says. “Family members need to be
Extensive preparation is necessary when moving patients to an new facility.
aware of what’s going on with their
patient the day of the move. This
reduces stress and anxiety and reassures
family members that their loved one is
safe.”
Transport Patients Safely
Planning to transport dozens of patients
at once to a new building takes a great
deal of planning and coordination.
Stack, Chambers, and Iati suggest the
following strategies to ensure a smooth
transition to the new building.
STRATEGY STRATEGY
Decide on the length
of moving day. The length of the
move depends on the anticipated num-ber
of patients to be transported, the
acuity of those patients, the length of
the moving route, and the amount of
equipment to be moved. NCH used a
software simulation modeling system to
determine the cycle time for each indi-vidual
patient transport and then
determine the length of the move based
on the amount of patients to be
moved. “The simulation software
allowed us to optimize our transport
routes and create an elevator utilization
plan because we didn’t want patients
on beds in elevator lobbies waiting to
be moved,” says Stack. “The model
worked—it predicted that our move
would take 4 hours and 30 minutes,
and we actually took 4 hours and 35
minutes.”
Overall, keeping the length of the
move as short as possible is important
for patient safety. “It is best to move as
quickly as possible and then recover,”
says Chambers. “With a prolonged
move, it spreads the institution and its
resources thinly over into two parts of
the campus for too long, which is less
safe than a structured, well-orchestrated
move.”
Pick the transport
routes ahead of time and run
mock moves.
Everything is simplified when patients
only need to be transported through
completely enclosed corridors to the
new building. But not all organizations
have the luxury of building new or
replacement towers on the current
campus. In some cases, organizations
have to transfer patients with ambu-lances
to the replacement hospital five
miles down the road. In these cases,
organizations must consider what is
going on within the community, such
as marathons or festivals, before sched-uling
the moving date. The season may
also affect the moving date (for example,
(continued on page 8)
www.jcrinc.com THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY November 2010 7
8. Moving Your Hospital to a New Facility,
Part 2:
(continued from page 7)
winter storms may cause delays in
ambulance transport).
Hopkins Children’s will be lucky
enough to move their patients through
enclosed corridors. “An internal move
saves us a great deal of anxiety,” says
Chambers. “Our biggest concern is
coordinating how fast patients can go
into the elevators.” NCH also had an
enclosed move, which helped simplify
the move, says Stack. “We knew the
cycle time for each patient transport
route,” says Stack. “We made a moving
pocket guide for everyone involved in
the move. The guide spelled out their
specific transport route, including a
map, and provided resource numbers,
including Incident Command Center’s
number.”
Decrease patient
STRATEGY
census levels. The move will go
much quicker if there are fewer patients
to transport. Hopkins Children’s plans
to decrease census levels by reducing the
amount of elective surgeries prior to the
moving date. In addition, organizations
can encourage physicians to discharge
any patients prior to the move, if it can
be done safely.2
Increase staffing
STRATEGY
levels. Extra staff will obviously be
needed to transport patients, but
increased staff in other areas of the hos-pital
will also be necessary. “We
increased staffing in the emergency
department because we knew patients
may have to be held there for a longer
time before they could be admitted to
the new building,” says Stack. “In addi-tion,
we decided we were not going to
have any babies born in elevators, so
anyone in active labor would not be
transported to the new labor and deliv-ery
unit. As a result, we ran two
completely staffed, parallel labor and
delivery units on the moving day. Both
units had enough obstetricians, anes-thesiologists,
and neonatologists
available for vaginal births or cesarean
sections.”
Set up an incident
STRATEGY
command unit and a move
command center. “Our incident
command was a group made up of four
to six people making decisions, with
one person in charge. We had radios
for communication with the transfer-ring
and receiving teams, Stack said.” It
may also be helpful to control traffic in
the command center so that communi-cation
via radios is not disrupted.2
Create transporting
STRATEGY
and receiving teams. At NCH, it
was important for a nurse who knew the
patient to be with the patient at all
times throughout the move. Therefore,
at the beginning of moving day, two
nurses heard a report on each patient
and one nurse became part of the trans-port
team from the old building while
the other nurse became part of the
receiving team in the new building. “So
if you were a nurse on the transport
team with four patients, you would have
two helpers to get your first patient
ready for transfer, transport that patient
to the new building, and hand off the
patient to the nurse on the receiving
team,” says Stack. “The transport nurse
would update the receiving nurse with
any new information on the patient
since report. Then, the transport nurse
would return to the old building, where
her next patient would be packed and
ready to go. The nurse on the transport
team also had the authority to say
whether or not a patient was stable
enough to be transported to the new
building.”
For intensive care patients, the
patient-to-nurse ratio was kept close to
1:1 so that the same nurse who trans-ported
the patient would remain with
the patient on the new unit. The trans-port
teams for intensive care patients
might also include respiratory thera-pists
if a patient was on a ventilator.
“In intensive care, the intensivist was
also available to assist during the
move,” says Stack. “And the neonatolo-gists
in the Special Care Nursery
actually accompanied some of the
babies to the new hospital.”
On moving day, Hopkins Children’s
plans to use three teams of nurses to do
the following:
1. Prepare patients for transport
2. Actually transport the patient
3. Receive the patient on the new
unit.
Hopkins Children’s will also include
way stations along transport routes
with essential staff, such as anesthesiol-ogists,
to ensure safe patient transfers.
Get information
STRATEGY
technology (IT) staff involved.
“Our IT staff was on each unit to make
sure that as soon as a patient was trans-ferred
to their new room, the patient’s
status was updated in the system so
that pharmacy, physicians, laboratory,
and dietary knew where the patient
was,” says Stack.
PS
References
1. Romano M.: Moving day: Relocating to a new
hospital puts staff's logistics skills to the test.
Mod Healthc 35:28, 30, Oct. 2005.
2. Schaufele M.: Moving day: Emergency com-mand
model helps children’s hospital Relocate.
Health Facil Manage 18:29–34, Nov. 2005.
Call for Papers
Are you or your organization
working on a project or policy that
will improve patient safety?
Why not share your ideas and
results with your colleagues
nationwide?
If you have a paper you would like
to submit for potential publication
in Perspectives on Patient Safety,
please send us an e-mail, at
patientsafety@jcrinc.com.
8 THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY November 2010 www.jcrinc.com
9. Alternative Surgical Site Marking
Compliance Strategies for the Joint Commission Universal Protocol for
Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery
Organizations need clear, specific policies on when alternative surgical site marking
processes could or should be used.
Wrong site, wrong proce-dure,
wrong person
surgery happens when a
procedure is executed on the wrong
body part, the wrong side of the
patient’s body, or the wrong patient.1
Wrong surgery procedures are consid-ered
“never events,” which means they
are, in theory, completely preventable
and thus should never happen.2
Marking the procedure site prior to
beginning the procedure is a critical
prevention activity. The Joint
Commission addresses this in require-ment
UP.01.02.01. (See sidebar on
page 11). According to this require-ment,
an appropriate site marking is
distinct, unambiguous, and visible after
the patient has been prepped and
draped. The mark is located at or near
the incision site and is sufficiently
permanent to remain visible after com-pletion
of skin preparation. This mark
can be the word “Yes,” the surgeon's
initials, or some other unambiguous
indication.
Although The Joint Commission rec-ommends
marking all surgical sites,
health care organizations are required, at
a minimum, to mark all cases involving
laterality, multiple structures (for exam-ple,
fingers, toes, lesions), or multiple
levels (for example, the spine). If a
patient requires multiple surgeries while
in a health care organization, the site
mark should be removed at the end of
the procedure unless the next surgical
procedure will continue on the same site.
To address situations in which a
physical site mark is not effective, prac-tical,
or sanctioned by the patient,
organizations must have an alternative
site marking process in place. Although
The Joint Commission is not prescrip-tive
as to what this alternative process
should be, it does require organizations
to define the process in writing and
ensure compliance with the process.
Addressing Challenges
Associated with Site Marking
Situations in which physically marking
the site may be anatomically impossible
or impractical include the following
examples:
• Gynecological procedures
• Dental procedures
• Procedures involving premature
infants, for whom the mark may
cause a permanent tattoo
In addition, the skin of some patients
may preclude effective site marking. For
example, a standard site mark may not
be visible on a patient with a significant
number of body tattoos or on a patient
whose skin has been severely burned. An
individual’s skin tone can also make site
marks hard to see.
Patients may also refuse site marking
in some cases. For example, patients
receiving facial surgery or breast sur-gery
may not wish to have the surgical
site marked with a permanent marker.
In such cases, the alternative process
should include patient education about
why site marking is appropriate, the
implications of refusing site marking,
and a clear description of the alterna-tive
site marking methods.
Types of Alternative Site
Marking
Organizations have used a variety of
methods to comply with this require-ment.
“Although there are many types
of alternative site marking approaches,
there are two we hear about most fre-quently,”
says Pat Adamski, R.N.,
M.S., M.B.A., executive director of
(continued on page 10)
www.jcrinc.com THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY November 2010 9
10. Alternative Surgical Site Marking
(continued from page 9)
The Joint Commission’s Standards
Interpretation Group. “The first
involves marking the procedure site on
an anatomical drawing kept near the
patient before and during the proce-dure.
To be effective, the drawing must
be displayed in a highly visible location
and must face the same direction as the
patient.” This approach may be helpful
when identifying the site of surgery for
premature infants, gynecological
patients, or during dental procedures.
As with standard site marking, a verifi-cation
process should exist that ensures
the drawing is marked correctly.
“The other approach is appropriate
in situations in which the site has been
marked, but the drape will cover that
mark,” says Adamski. “In these cases,
the provider would mark the site and
then as the patient is draped, mark the
drape.” Similar verification processes
should be involved in marking the site
and marking the drape to ensure the
markings are consistent. Staff should
also ensure that the drape is secure, so
that it does not inadvertently move off
the site before or during the procedure,
according to Adamski.
Some organizations also use fluo-roscopy
and other radiological
techniques to help with site marking in
internal procedures such as spine sur-gery.
“In most cases, these are used in
conjunction with an outer form of site
marking to identify the general loca-tion
of the surgery and then pinpoint
the specific location,” says Adamski.
Standardizing the Approach
To ensure consistent and appropriate
use of alternative site-marking proce-dures,
such procedures should be
standardized throughout an organiza-tion
where possible. “Having a
consistent method for alternative site
marking helps build familiarity with
the process and can prevent error and
misunderstanding,” Adamski says.
Organizations may want to analyze
the surgical procedures occurring
within their facilities and determine
which qualify for alternative site mark-ing,
then develop a consistent approach
to the process and train staff on when
and how to use that approach.
Organizations should consider
including alternative site marking on
their presurgical checklist. This can not
only help document the use of the alter-native
approach, but also help staff
remember that when traditional site
marking is not appropriate, a defined
alternative approach should be followed.
Involving the Patient Is
Important
Regardless of the type of alternative site-marking
process an organization uses,
this process should involve the patient.
For this to be done in a meaningful way,
site marking should happen before the
patient is significantly sedated.
Participation may be precluded by a dis-ease
state or heavy sedation; however,
sedation by itself does not necessarily
prevent the patient from participating in
the alternative site marking process. The
patient’s capacity to participate must be
based on an individual assessment. In
cases of nonspeaking, comatose, or
incompetent patients or children, the
“patient involvement” in the site-mark-ing
process should be handled in the
same way as the informed consent
process. Whoever has authority to pro-vide
informed consent for the patient to
undergo the procedure would, as appro-priate,
participate in the alternative
site-marking process.
Monitoring to Ensure
Compliance
Simply having an alternative site
marking process is not sufficient to
be in compliance with the Universal
Protocol. Organizations must ensure the
process is used correctly. “Organizations
should be monitoring their use of alter-native
site-marking procedures,”
Adamski says. “This can be done in
many ways, including through chart
reviews, checklist reviews, direct observa-tions,
conversations with surgical team
members, and so on.”
Organizations should ensure staff
members are familiar with the organiza-tion’s
alternative site-marking procedures
and know when to use them.
Organizations should also identify how
frequently such alternative procedures
occur and whether they are used appro-priately.
If monitoring efforts show that
alternative procedures are occurring
more frequently than standard marking
procedures, a closer examination of the
issue may be warranted.
Wrong-Site Surgery a
Persistent Problem
Despite the fact they are preventable,
wrong surgery errors continue to plague
health care organizations around the
world. Although the frequency of these
types of errors is difficult to quantify
because of underreporting issues, avail-able
data is nevertheless alarming. For
example, since 1995, when The Joint
Commission began reviewing sentinel
events and their root causes, wrong site
surgery has become the most frequently
reported category of sentinel events.3
Although greater awareness and report-ing
may contribute to the numbers,
surgical errors of this type clearly con-tinue
to occur.4
One recent study suggests wrong-site
surgery happens in 1 out of
112,994 cases.5 These numbers repre-sent
actual cases; however, the number
of near misses is much higher.6
The Patient Safety Authority of
Pennsylvania—which collects data on
wrong-site surgery, both actual and
prevented—indicates receiving reports
of an average of one wrong-site surgery
event (either actual or near miss) every
six days since mandatory state report-ing
began in the early 2000s.7
Although many of these near misses
and surgical confusions cause little or
10 THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY November 2010 www.jcrinc.com
11. no permanent injury, the risks are pres-ent
for a serious, irreversible event that
can permanently scar a patient, family,
and provider.8
PS
References:
1. Senders J., Kanzki R.: The egocentric surgeon
or the roots of wrong-side surgery. Qual Saf
Health Care 17:396–398, Dec. 2008.
2. Stahel P., Mehler P., Clarke T., et al.: The 5th
anniversary of the “Universal Protocol”: Pitfalls
and perils revisited. Patient Safety in Surgery, Jul.
2009. http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC2712460 (accessed Sept. 1, 2010).
3. Joint Commission International: Performance
of Correct Procedure at Correct Body Site.
Patient Safety Solutions 1, May 2007.
4. Wrong-site surgery is No.1 among sentinel
events—Are you at risk? Same-Day Surgery
31:113–124, Oct. 2007.
5. Kwan M., Studdert D., Zinner M., et al.:
Incidence, patterns, and prevention of wrong-site
surgery. Archives of Surgery 141:353–357,
Apr. 2006.
6. Edwards P.: Ensuring correct-site surgery.
Provenance and Peer Review 18:168–171, Apr.
2008.
7. Blanco M., Clarke J., Martindell D.: Wrong
site surgery, near misses, and actual occur-rences.
AORN Journal 90:215–217, Aug.
2009.
8. Sime J., Ngo Y., Khan S.: Surgical confusions
in ophthalmology. Arch Ophthalmology
125:1515–1521, Nov. 2007.
Effective Handoff Communication, Part 2
(continued from page 5)
environment and develop clear expecta-tions
for which each individual,
department, patient care team, and
administrator will be held accountable.
Finally, organizations also need to regu-larly
evaluate how well their new systems,
policies, and procedures are working and
make adjustments when necessary.
What is the end result of this kind of
sustained, positive change? Creating the
culture you wanted in the first place.
Michael S. Woods, M.D., M.M.M. is a lead-ership
expert, surgeon, and author of several books,
including In a Blink, Healing Words, Civil
Leadership, and was editor of Cultural
Sensitivity: A Pocket Guide for Providers.
Dr. Woods is a recognized authority on
provider–patient communication and relation-ships,
patient satisfaction, and strategies to reduce
medical malpractice. Dr. Woods is the founder of
Civility Mutual® Educational Services, an organi-zation
dedicated to helping physicians and health
care staff with relationship-based care and improv-ing
patient–provider communication. He is the
vice president of medical affairs for the Johnson
Memorial Medical Center in Stafford Springs, CT.
References
1. Landro L.: Hospitals combat errors at the
‘hand-off.’ Wall Street Journal. June 28, 2006.
2. The Joint Commission: Improving Handoff
Communication. Oak Brook, IL: Joint
Commission Resources, 2007.
3. Hoffman J.: CRICO’s Handoff-related cases.
Forum 25:4, Mar. 2007. http://www.rmf.
harvard.edu//files/documents/Forum_V25N1.
pdf (accessed Sept. 20, 2010).
The Joint Commission on Handoff Communication
The Joint Commission defines handoff as “the real-time process of passing patient-specific
information form one caregiver to another or from one team of caregivers to
another for the purpose of ensuring the continuity and safety of a patient’s care.”4
In 2006, in order to guide health care organizations through the process of improving
handoff communication processes, The Joint Commission created National Patient
Safety Goal 2E (later known as NPSG.02.05.01). As of January 1, 2010, handoff com-munications
transitioned out of the National Patient Safety Goals and into Standard
PC.02.02.01, Element of Performance 2: “The hospital’s process for handoff communi-cations
provides for the opportunity for discussion between the giver and receiver of
patient information.”
According to The Joint Commission’s Sentinel Events Database, communication break-downs
are a contributing factor in 65% of sentinel events, the number one driver of all root
causes in the database. (Note that the Sentinel Events Database information is collected
through voluntary reporting and potentially represents only a fraction of actual events.)
The Joint Commission Center for Transforming Healthcare is currently working on an
improvement project related to handoff communications. The project began in August
2009, and published solutions are expected in December 2010. Selected by eight lead-ing
hospitals and health systems, the Hand-Off Communications Project team includes
hospital leadership, clinicians and staff, and the Center’s Black Belts and Green Belts.
The Joint Commission Center for Transforming Healthcare uses Robust Process
Improvement™ (RPI) methods and tools in the development of its solutions. RPI is a
fact-based, systematic, and data-driven problem-solving methodology. It incorporates
specific tools and methods from Lean Six Sigma and change management methodolo-gies.
The handoff solutions will be integrated in the center’s Targeted Solutions Tool™
(TST). (See page 2 for more information about the TST.)
4. Solet D., Norvell M., Rutan G., et. al.: Lost in
translation: Challenges and opportunities in
physician-to-physician communication during
patient handoffs. Acad Med 80:1094-1099,
Dec. 2005.
5. Arora V., Johnson J.: A model for building a
standardized handoff protocol. Jt Comm J
Qual Patient Saf 32:646–655, Nov. 2006.
6. The Joint Commission: Handoff
Communications: Toolkit for Implementing the
National Patient Safety Goal. Oak Brook, IL:
Joint Commission Resources, 2008.
7. Chan-Macrae M., O’Malley T., Poon E.:
Partners HealthCare clinical transitions project.
Forum 25:16–17, Mar. 2007.
http://www.rmf.harvard.edu//files/documents/
Forum_V25N1.pdf (accessed Sept. 20, 2010).
8. Haig K., Sutton S., Whittington J.: SBAR: A
shared mental model for improving communi-cation
between clinicians. Jt Comm J Qual
Patient Saf 32:167–175, Mar. 2006.
9. Shaw T.: Communication: Making transitions
safer with standardized handoffs. Paper presented
at the Society for Pediatric Anesthesia 23rd
Annual Meeting, New Orleans, Oct. 16, 2009.
10. Greenberg C., Wilkie A.: Communication
Handoffs: One hospital’s approach. Forum
25:10–11, Mar. 2007. http://www.rmf.
harvard.edu//files/documents/Forum_V25N1.
pdf (accessed September 20, 2010).
www.jcrinc.com THE JOINT COMMISSION PERSPECTIVES ON PATIENT SAFETY November 2010 11
12. Volume 10, Issue 11, November 2010
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