opportunity to voice concerns. Every team member
needs to be actively involved in the process, not just
filling in check marks on a form. There should be verbal communication.
9. Do not multi-task. Minimize distractions and implement
a standardized process that is used by everyone in the
facility. Then monitor for compliance.
10. Examine processes for inconsistencies and seek to
understand the cause of variation.
Werner and Richardson also point out a number of
resources at the disposal of OR teams to help in addressing wrong-site concerns. “There are many ways to
promote a culture of safety and develop processes and
tools for the implementation of successful patient safety
programs. Keeping the process simple and consistent is a
good strategy,” they state.
In particular they point to the following as tools that could
be adopted in moving an organization forward:
• AORN Correct Site Surgery Tool Kit.
• Collaborative Crew Resource Management (CRM). CRM
is a communication methodology developed by the aviation
industry, based on team-centered decision making systems.
• Team STEPPS. Team Strategies and Tools to Enhance
Performance and Patient Safety, developed by the
Department of Defense Patient Safety Program in collaboration with the Agency for Healthcare Research and
Quality (AHRQ) to train staff to work as a team.
• Video/Video vignettes that are made with collaboration
of staff from different levels to encourage engagement in
the learning process.
• World Health Organization (WHO) Protocols.
“No matter what tools you use to develop a culture of
safety,” they add, “it is important to consistently validate
participant ideas and thoughts to ensure full engagement in
the process.” The duo also feels that once processes are in
place, there are three areas that are key in improving compliance communication regarding wrong site protocols:
1. Achieve compliance across disciplines.
• Make this the “burning platform” to create a sense of
urgency and to help all parties understand that the status
quo is no longer acceptable.
• Utilize Safety Rounds or Safety Huddles to develop and
maintain team commitment.
2. Change behavior.
• Empower stakeholders to create a solution.
• Encourage and support teamwork and communication.
• Training and education are an important part of this process.
3. Implementation of prevention tools and processes that
ensure correct site surgery, which can include:
• Physical reminders.
• Preserving a quiet environment.
• Ensuring checklists are used.
“Many clinicians may believe or expect that building
a culture of patient safety will be simple, but in reality, it
is harder and more complex than ever,” offer Werner and
Richardson. “Developing and implementing effective strategies to improve the use of Universal Protocols, to promote
positive patient outcomes and to support team collaboration and clear communication is vital”
The Joint Commission Center for Transforming
Accessed July 18, 2014.
Video: Reducing the Risk of Wrong Site Surgery. http://
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