New Operating Room Protocol That May Save Your Life

By Dr. Joseph Andris Anesthesiologist

One of the more important innovations, relating to anesthesia, is the formation of Highly Reliable Surgical Teams or HRST. Developed from the input of many contributing groups, it is the latest safety protocol for the operative theater. It was established to eliminate mistakes, educate operating room personnel, improve efficiency, personalize each operation and eliminate waste. The basis of the need for HRST comes from statistics revealing mistakes in the operating rooms throughout the country. After careful evaluation of these statistics, it was determined that the vast majority of these mistakes could be reduced or eliminated by changing the attitude and thinking of all operating room personnel, including the anesthesiologists, surgeons, technicians and nurses. The solution was fairly simple and involved little, if any, additional time to the anesthesia-surgical process. Essentially, the additional safety process is divided into two parts. One at entering the operating room and the second half is performed prior to departing the operating room. In my hospital, the initial protocol involves the "time out". The "time out" occurs when the patient arrives in the operating room and before they are moved from their bed to the operating table. All members of the operating room team must cease all activity and focus their attention on the patient.The first member of the team presents their pertinent information relating to the ensuing surgical procedure. The anesthesiologist or the surgeon usually begins by identifying the patient employing at least two identifiers. Usually, these are the patient's name and medical record number confirmed by the patients themselves, if possible, and by identifying the medical record numbers on the patient's wrist band with that on their chart and identification card.

If the surgeon starts, he or she states the type of surgery to be performed and the site of the surgery which has already been marked prior to entering the O.R. Next, he or she announces that all the equipment necessary for the procedure is present and that the patient is in the correct position so that the surgery may be performed without difficulty. The anesthesiologist then announces the type of anesthetic, confirms the position in which the patient will be placed, the padding of the patient to prevent injury while under the effects of anesthesia, medications administered to the patient prior to entering the operating room, and the monitors to be employed to measure the patient's vital signs with emphasis on maintaining the patient's temperature as close to normal as possible. The cascade reporting continues until all involved in the surgery have voiced their respective obligations or concerns. After this, the patient is moved to the operating room table and the anesthetic begins. The second portion of the HRST process occurs as the surgical procedure is ending. The content here ensures that no equipment or instrument is left in the open surgical site. Also at this time, anyone in the room may discuss any concerns involving the procedure or contribute observations to improve the whole process. The last segment of this portion of the HRST protocol occurs before the patient leaves the operating room. At this juncture the time is set to have the next patient on the schedule safely and efficiently present in the operating room for their respective surgery. This very simple process, which takes minutes, has already reduced errors and inefficiencies such as operating on the wrong patient, the wrong type of surgery being performed, the wrong surgical site, medication allergies, and leaving surgical instruments in a patient. Although the above mistakes do not commonly occur, when they do, the results can be catastrophic. HRST is one of those rare improvements that greatly affect positive results with little or no increase in cost to the consumer. Dr. Joseph Andris, D.O., is a board certified anesthesiologist. For the past nine years, he has been practicing in the San Francisco Bay Area. He serves as director of the OR as well as assistant chief of anesthesia at Kaiser Permanente's San Rafael campus. Dr. Andris attended Villanova University and the Philadelphia College of Osteopathic Medicine. He completed residencies in both internal medicine and anesthesiology at West Virginia University, where he also taught as an assistant professor while practicing medicine. Send your questions to Joe@smartnow.com.

Operating Room Nurses Ask for Time Out

June 16, 2010 - The Association of periOperative Registered Nurses (AORN), the largest membership organization of operating room nurses in the United States, is drawing on its ability to influence patient safety practices in the OR with the national launch of a Time Out Commitment campaign. The new, year-round campaign begins on National Time Out Day, June 16, and is designed to increase awareness of and compliance to taking a time for every patient, every time before the start of a surgical procedure. Time out allows the entire surgical team to verify the correct person, procedure, and site. Due to the size of its membership, AORN expects the Time Out Commitment campaign to reduce the risk of surgical errors in thousands of hospitals and ambulatory surgical centers across the United States. Despite efforts to address errors such as wrong site surgery, The Joint Commissions latest update to its sentinel event statistics indicates that wrong site surgery is still the most common sentinel event reported. Between January and March of 2010, 18 wrong site surgeries were reported to The Joint Commission. These numbers illustrate the important role perioperative nurses can play in speaking up for the patient and promoting safety checks to catch errors before they happen. AORN, with more than 40,000 OR nurse members, believes a campaign that emphasizes commitment will inspire awareness, collaboration and compliance throughout the operating room. Every member of the surgical team has unique responsibilities as they prepare patients for surgery, said Linda Groah, RN, MSN, CNOR, NEA-BC, FAAN, the Associations executive director and CEO. We believe that by starting an ongoing time out campaign with our members, and by providing them with education and awareness tools for the entire team, pre-op practices and surgical outcomes will improve. With the support of the World Health Organization and The Joint Commission, AORN has assembled several tools and provided new online resources to support their members as time out champions. In addition to a downloadable poster that proclaims, I Commit to Time Out for Every Patient, Every Time, the Association has created an online sign-up where OR professionals can publicly support the campaign by adding their names and the names of their facilities. The WHOs surgical checklist, The Joint Commissions Universal Protocol and the AORN Comprehensive Surgical Checklist are also available free online as well as videos that demonstrate the time out procedure. In addition to providing online time out education resources, AORN has initiated an OR professionals discussion group on OR Nurse Link, the associations online community. The discussion, led by AORN president Charlotte Guglielmi, RN, BSN, MA, CNOR, perioperative nurse specialist at the Beth Israel Deaconess Medical Center in Boston, will help facilitate time out conversations in ORs across the country, and open up new communications channels to share best practices. Some of the participants will be there to learn while others will be sharing their experience and stories of successful practices, said Guglielmi. This forum will inform surgical teams about exactly what needs to be done to achieve time out for every patient, every time.

SAN DIEGO -- It's understandable many people have a fear of surgery because there are so many risks. But there is one danger you may not have thought of -- nurses and other members of the surgical team being afraid to speak up if they spot a problem. There is growing evidence that poor communication between surgical teams and doctors is the leading cause of avoidable surgical errors. Mistakes like the wrong patient or procedure, or the right procedure on the wrong part of the body have happened in the operating room. "There are just too many things that are happening in an operating room all at once for one person to be in charge," said Scripps Memorial Chief of Staff Dr. Dana Launer. Studies show that a big part of the problem is the intense atmosphere of the operating room. "There are moments where it is nice and calm -- I call it organized chaos," said surgical nurse Christine Pedroni. It's a place where surgeons are captains of the ship. As a result, nurses and members of the surgical team can be afraid to speak up, but that's changing in operating rooms across the nation and in San Diego. Many hospitals have implemented a pre-flight check plan -- a brief time out before surgery to encourage anyone in the operating room who has a concern to speak out, 10News reported. Surgical teams at Scripps Memorial Hospital in La Jolla use a time out system to empower everyone on the surgical team to delay or even suspend a surgery if the team isn't in agreement. "I think we are doing with our time out procedure what the airlines do before they take off on a flight," said Launer. "In the 21st century surgeons, in spite of their notorious big egos, understand they are part of the team and the collaborate effort that is important to take care of a patient." he said. Pedroni says the working environment has changed since she began her career 32 years ago. "There were moments back then that it was difficult to speak up," said Pedroni. Now surgeons value all input from their team. "We take our jobs very seriously, but there are checks and balances that take place every day along the way before, during and after every procedure to ensure that the patient is protected," said Launer. It's a safety pause that is helping hospital workers catch near misses. Scripps Memorial says the time out method has helped prevent surgical errors. Healthcare giant Kaiser Permanente is implementing the same type of safety pause in all 30 of its hospitals across the country. Copyright 2006 by 10News.com. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Surgery Teams Across the U.S. Take Time Out in the Operating Room
AORN National Time Out Day Supports Correct Patient, Correct Procedure, and Correct Surgical Site DENVER, June 12 /PRNewswire-USNewswire/ The Association of periOperative Registered Nurses (AORN) annually promotes National Time Out Day, this year on June 17, to emphasize the importance of surgical teams taking a time out to confirm vital patient information before beginning every invasive procedure. Wrong-site surgery and other preventable mistakes still occur too frequently in operating rooms even though The Joint Commission requires all accredited health care facilities to practice a time out as part of its Universal Protocol and the World Health Organization (WHO) provides a safety checklist for surgical teams to use in operating rooms. Surgical teams all understand the importance of pausing before invasive procedures so they can communicate as a group and confirm key information about the patient and procedure yet, as individuals, they can be unclear about their role in its facilitation. Brian Tepp, AORN membership director, noticed this common concern in Member Talk, the Associations online discussion board. Members were asking each other for ideas and tips on how they could assure an effective time out, said Tepp. Based on this member feedback, AORN extended an open invitation to hospitals and ambulatory surgery facilities to videotape their teams process for the Association to share on its web site as examples. We thought videos would be an excellent method to demonstrate best practices in action. As the leader in advocating for excellence in perioperative practice and healthcare, we always are looking for strategies that will further protect surgical patients, said Patrick Voight, RN, BSN, MSA, CNOR, AORN president. National Time Out Day and the videos will remind and teach surgical staff members to focus on the safety of each and every patient they see. We are proud of this initiative and the commitment from across the country. Dozens of videos were reviewed by clinical editors of AORN recommended practices and evaluated according to criteria set for compliance using either the WHO check list or the components of the Universal Protocol depending on the facilitys respective procedure. The judges selected ten videos that were strong in meeting each component of the check list and, while minor discrepancies from the AORN recommended practices were considered as tie-breakers in the assessment, they did not prevent a video from being recommended for use on the AORN web site. The 2009 National Time Out Day videos are: Childrens Hospital Boston Exempla St. Joseph Hospital Denver Florida Hospital Orlando Jennersville Regional Hospital Westgrove, Penn.

Marion General Hospital Marion, Ohio Memorial University Medical Center Savannah, Ga. NYU Langone New York St. Joseph Mercy Howell, Mich. University Hospital Cincinnati White River Medical Center Batesville, Ark. The ten facilities will each receive a copy of AORN Perioperative Standards and Recommended Practices, 2009 edition as a gift from ClearCount Medical Solutions, Inc. This year, AORN collaborated to promote awareness of time out with the American Nurses Association, the American Association for Accreditation of Ambulatory Surgical Facilities, the Council on Surgical & Perioperative Safety, and The Joint Commission to remind professionals, health care providers, and administrators that Every Day is Time Out Day. As part of this patient safety initiative, AORN revised its Correct Site Surgical Tool Kit to assist health care providers in implementing The Joint Commission Universal Protocol. The tool kit contains a variety of resources to educate health care providers about the Universal Protocol and to assist them with its implementation. To view the 2009 National Time Out Day videos and learn more about National Time Out Day, go to aorn.org/NationalTimeOutDay About AORN The Association of periOperative Registered Nurses represents approximately 42,000 Registered Nurses in the U.S. and abroad who facilitate the management, teaching and practice of perioperative nursing, or who are enrolled in nursing education or engaged in perioperative research. Its members also include perioperative nurses that work in related business and industry sectors. AORNs mission is to promote safety and optimal outcomes for patients undergoing operative and other invasive procedures by providing practice support and professional development opportunities to perioperative nurses. For more information, visit www.aorn.org. SOURCE Association of periOperative Registered Nurses Source: redOrbit (http://s.tt/16nni)

Operating Room Nurses Ask For Time Out

Main Category: Nursing / Midwifery Article Date: 10 Jun 2010 - 8:00 PDT

Current ratings for: 'Operating Room Nurses Ask For Time Out'

The Association of periOperative Registered Nurses (AORN), the largest membership organization of operating room nurses in the United States, is drawing on its ability to influence patient safety practices in the OR with the national launch of a "Time Out Commitment" campaign. The new, year-round campaign begins on National Time Out Day, June 16, and is designed to increase awareness of and compliance to taking a time for every patient, every time before the start of a surgical procedure. Time out allows the entire surgical team to verify the correct person, procedure, and site. Due to the size of its membership, AORN expects the Time Out Commitment campaign to reduce the risk of surgical errors in thousands of hospitals and ambulatory surgical centers across the United States. Despite efforts to address errors such as wrong site surgery, The Joint Commission's latest update to its sentinel event statistics indicates that wrong site surgery is still the most common sentinel event reported. Between January and March of 2010, 18 wrong site surgeries were reported to The Joint Commission. These numbers illustrate the important role perioperative nurses can play in speaking up for the patient and promoting safety checks to catch errors before they happen. AORN, with more than 40,000 OR nurse members, believes a campaign that emphasizes commitment will inspire awareness, collaboration and compliance throughout the operating room. "Every member of the surgical team has unique responsibilities as they prepare patients for surgery," said Linda Groah, RN, MSN, CNOR, NEA-BC, FAAN, the Association's executive director and CEO. "We believe that by starting an ongoing time out campaign with our members, and by providing them with education and awareness tools for the entire team, pre-op practices and surgical outcomes will improve." With the support of the World Health Organization and The Joint Commission, AORN has assembled several tools and provided new online resources to support their members as time out champions. In addition to a downloadable poster that proclaims, "I Commit to Time Out for Every Patient, Every Time," the Association has created an online sign-up where OR professionals can publicly support the campaign by adding their names and the names of their facilities. The WHO's surgical checklist, The Joint Commission's Universal Protocol and the AORN Comprehensive Surgical Checklist are also available free online as well as videos that demonstrate the time out procedure.

In addition to providing online time out education resources, AORN has initiated an OR professionals' discussion group on OR Nurse Link , the Association's online community. The discussion, led by AORN president Charlotte Guglielmi, RN, BSN, MA, CNOR, perioperative nurse specialist at the Beth Israel Deaconess Medical Center in Boston, will help facilitate time out conversations in ORs across the country, and open up new communications channels to share best practices. "Some of the participants will be there to learn while others will be sharing their experience and stories of successful practices," said Guglielmi. "This forum will inform surgical teams about exactly what needs to be done to achieve time out for every patient, every time." Source AORN, Inc.

National Time Out Day - June 13

Are you committed and is your team committed to conducting a safe, effective time out for every patient, every time? National Time Out Day is a powerful tool that supports surgical nurses ability to speak up for safe practices in the operating room. Initiated as an annual awareness campaign by AORN in 2004, it has been consistently supported by The Joint Commission, the World Health Organization, and the Council on Surgical and Perioperative Safety (CSPS) for its ability to increase awareness of safe practices that lead to optimal outcomes for patients undergoing surgery and other invasive procedures. This year, AORN urges members to evaluate how their time out fits into broader efforts to provide high quality care to every patient, every time. A poorly executed time out or lack of team communication may indicate areas for improvement within a safety culture.
Strengthen your time out practice

Education

Correct Site Surgical Tool Kit AORN's Correct Site Surgery Tool Kit offers a variety of resources to assist health care providers in implementing The Joint Commission's Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. Free to members*.

Just Culture Tool Kit - Improve Patient Safety by Creating a Just Culture Creating a just culture promotes both professional accountability and reporting of medical errors and fosters a professional milieu that includes reporting systems and processes for improving patient safety through organized analysis. As part of AORNs commitment to patient safety improvement, we created a position statement to promote just culture and a tool kit to help you implement it. Free to members*.

Human Factors in Health Care Tool Kit Team Training Using Human Factors to Enhance Patient Safety Human factors skills are crucial to health care teams in safety-critical environments. When health care teams work well together, threats and errors can be recognized, prioritized, and managed before an adverse outcome becomes a reality. Free to members*.

Surgical Safety Checklist Script AORN's Correct Site Surgery Tool Kit offers a variety of resources to assist health care providers in implementing The Joint Commission's Universal Protocol for Preventing Wrong Site, Wrong Procedure

and Wrong Person Surgery. Free to members*.

AORN Comprehensive Surgical Checklist This single surgical checklist includes safety checks outlined in the World Health Organizations (WHO) Surgical Safety Checklist and checks within The Joint Commissions Universal Protocol to meet accreditation requirements. It is useful in all facility types hospital ORs, ASCs, and physician offices and is provided as a Word document to enable adjustments according to practice setting and specialty. All AORN Tool Kits are free to members. To learn about AORN membership and other member benefits, visit http://www.aorn.org/Membership/Membership.aspx

The Joint Commission Universal Protocol World Health Organizations Surgical Safety Checklist

Get it straight from AORN.org: http://www.aorn.org/2012timeout/#ixzz1xLAz0xkM

PERIOPERATIVE ISSUES
February 1, 2007 0 Comments Posted in Articles, Association Of Perioperative Registered Nurses (AORN), Operating Room (OR), Perioperative, Guidelines & Regulations Print

The Association of PeriOperative Registered Nurses (AORN) is now in the midst of performing an evaluation of the Universal Protocol, which was created and implemented to eliminate wrong-site, wrong-procedure, and wrong-patient surgery. The July 2003 Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) was created in direct response to the ongoing incidence of wrong-site, wrong-procedure, and wrong-patient surgeries. The protocol actually became required on July 1, 2004, for all healthcare organizations accredited by the Joint Commission. It was based in part on the Joint Commissions 2003 and 2004 National Patient Safety Goals.1 The main elements of the protocol include the following: 1. A pre-operative verification process 2. Marking the operative site 3. Taking a time out immediately before the procedure begins 4. Adapting the requirements to non-operating room settings, to include bedside procedures. Any of these events the wrong site, wrong procedure, or wrong patient are considered sentinel events by JCAHO. A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury. When the Joint Commission realized that these events were still occurring even after sentinel event alerts issued in 1998 and 2001, it convened a wrong-surgery summit. The summit was used as an opportunity for multiple organizations and associations to come to a consensus on a Universal Protocol for all healthcare settings. The eventual protocol was endorsed by more than 50 professional associations and organizations, including: the Agency for Healthcare Research & Quality, the American Academy of Pediatrics, the American Association of Nurse Anesthetists, the American College of Surgeons, the American Hospital Association, the American Medical Association, the American Nurses Association, the American Society of Anesthesiologists, the American Society of General Surgeons, the Association of periOperative Registered Nurses, and the National Patient Safety Foundation. The Universal Protocol states its purpose very simply: Wrong-site, wrong-procedure, wrong-person surgery can be prevented. The Universal Protocol has established clear procedures to ensure that the right patient is the one undergoing the procedure. It is essential to utilize multiple, complementary strategies, the protocol points out, to ensure overlap.

Joint Commission-accredited organizations are required to follow the Universal Protocol for patients having operative or other invasive procedures. AORNs Evaluation AORN is evaluating the Universal Protocol to establish what factors promote the use of the protocol, as well as which factors serve as obstacles to its execution. There will be a second summit on wrong-site surgery held later this year, during which the results of the evaluation will be offered for discussion. Data from individual participants, which is still being collected, will be aggregated, so that no responses will be linked to an individual participant in the survey. To access the survey, visit www.questionpro.com/akira/TakeSurvey?id=570034. The reason for the evaluation is that these sentinel events may still occur, and not all medical professionals are instituting the time out as is recommended. Deborah F. Mulloy, MSN, CNOR, of Massachusetts General Hospital, and a perioperative education consultant for AORN, will be performing a dissertation study on the results of the Universal Protocol, and will also evaluate the effect of the AORN Correct Site Surgery Tool Kit on implementation of the protocol. With any new protocol, it is critical to evaluate its effectiveness and how well it supports practice, Mulloy observes. The Universal Protocol is supported on the intellectual basis. However, in practice, distractions can occur, and there is only one recent study (Kwaan et al 2006) about it, which suggests that the Universal Protocol is effective in approximately two-thirds of the cases of wrong-site surgery. Since the protocol is not always being followed, AORN wants to ascertain how to get physicians, nurses, and other healthcare workers to fully observe the Universal Protocol. The association is not in a position to enforce compliance, Mulloy points out, but, she says, They can recommend practices based on research and standards and encourage members to follow them. In addition, they can provide supportive materials to members, as in this case the Correct Site Surgery Tool Kit. Professionals have an obligation to read and follow the best practices every day. There are two simple steps that can help facilitate the use of the protocol, she adds teamwork and communication. Everyone needs to participate, and no one should believe they are exempt from the process, she says. The term everyone includes surgeons, nurses, and other support staff even if they think they dont need to follow the guidelines. They must be re-educated to understand that JCAHO certification requires this participation in the time out, with only a few exceptions, which are clearly noted in the sample hospital protocol (see references below). My dissertation study has two aims: to determine if there has been a change in the incidence of wrongsite surgery during the period from January 2000 through July 2006, and to evaluate the effect of the AORN Correct Site Surgery Tool Kit on implementation of the Universal Protocol for wrong-site surgery, Mulloy explains. A survey research design will be used to evaluate the effect of the AORN Correct Site Surgery Tool Kit on implementation of the Universal Protocol for Preventing Wrong Site, Wrong Patient, Wrong Procedure SurgeryTM, and to document the incidence of Wrong Site Surgery.

The Correct Site Surgery Tool Kit from AORN is offered to assist healthcare facilities in observing the Universal Protocol for preventing wrong site/procedure/ patient surgery. The tool kit contains multiple resources for educating medical staff about the Universal Protocol and to assist in its implementation throughout the healthcare facility. According to AORN, it includes the following components:

An educational program on CD-ROM A pocket reference card (in pdf form) outlining all of the steps necessary to promote patient identification, site marking, and the time out before surgery commences A template (in pdf form) for a policy to assist healthcare providers in developing a facility policy for applying the Universal Protocol Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery and Guidelines for Implementing the Universal Protocol Frequently asked questions (in pdf form) from the Joint Commission and AORN Letters to nurses, physicians, facility chief executive officers, and healthcare risk managers, encouraging standard implementation of the Universal Protocol throughout all facilities Information for patients (in pdf form) about the Universal Protocol and healthcare safety Additional resources regarding correct-site surgery Some of the steps within the universal protocol address previous issues with marking the operative site, for example. On premature infants, the marking can cause permanent tissue discoloration, so the protocol is exempted in this cohort.

The Joint Commissions guidelines for implementing the Universal Protocol state that additional exceptions to marking include single-organ cases (such as a caesarean section or cardiac surgery); interventional cases in which the catheter/instrument insertion site is not predetermined (such as cardiac catheterization); and teeth (but the operative tooth name(s) must be noted on documentation, or the operative tooth must be marked on the dental radiographs or dental diagram). When the correct person, procedure, and site are verified before the surgery, this must be done multiple times when the procedure is first scheduled, at the time of the patients admission, any time the patients care is transferred to another caregiver, and before the patient leaves the preoperative area or enters the operating room. The patient should be involved, awake, and aware, if this is possible, so that he or she can immediately point out discrepancies or incorrect information about the procedure. When the operative site is marked, it should be marked at or near the incision site, not on a nonoperative site. And the markings should not be ambiguous. An x could indicate Cut here or the opposite, Dont touch. Instead, the Joint Commission recommends utilizing initials or a Yes to indicate where the incision should go. Additionally, the mark should be visible even after the patient is prepped and draped, and should made with a permanent marker or one that is still visible after the skin has been prepped. Specifically, the Joint Commission says, Adhesive site markers should not be used as the sole means of marking the site. Not only that, but the entire healthcare facility must utilize the same method and type of marking throughout the building or system.

At a minimum, mark all cases involving laterality, multiple structures (fingers, toes, lesions), or multiple levels (spine), the protocol says. In addition to pre-operative skin marking of the general spinal region, special intraoperative radiographic techniques are used for marking the exact vertebral level. Site marking should be done by the person performing the procedure, and must take place with the patient awake, aware, and involved. There must still be a final verification of the site mark during the time out. In addition, the healthcare facility should have a defined procedure in place in case a patient refuses site marking. The time out must take place in specific locations and at multiple times, according to the protocol. It must be conducted in the procedure area just before the surgery begins, and must involve the entire operative team. At a minimum, it must be documented, involve active communication, and must include a correct recognition of patient identity, side and site of surgery, and procedure type, as well as correct patient position and availability of required implants and special equipment or requirements for the procedure. There should also be a system in place for resolving differences in staff responses during the time out. If there is a non-OR setting being used for the procedure, then the following procedures apply:

Site marking for any procedure with laterality, multiple structures or levels Verification, site marking, and time out procedures that are consistent throughout the facility

Exceptions apply in the following case: Site marking is unnecessary when the individual performing the procedure is in continuous attendance with the patient from the decision to do the procedure, to patient consent, through the procedure itself. However, the time out verification still must be performed.2 Resources A sample of a hospital internal policy on the Universal Protocol can be found at: www.aorn.org/toolkit/pdf/PolicySample.pdf, and letters for nurses, physicians, and other medical staff emphasizing the important of implementation are available at www.aorn.org/toolkit/letters.asp . JCAHO lists its expectations for implementation of the Universal Protocol at www.jointcommission.org/NR/rdonlyres/DEC4A816-ED52-4C04-AF8CFEBA74A732EA/0/up_guidelines.pdf Information on patient safety is available at:

Agency for Health Care Research and Quality www.ahrq.gov4 Association of periOperative Registered Nurses (AORN) Patient Safety First www.patientsafetyfirst.org Institute for Safe Medication Practices www.ismp.org Institute of Medicine (IOM) www.iom.edu Joint Commission on Accreditation of Health Care Organizations (JCAHO) www.jcaho.org/index.htm National Patient Safety Foundation www.npsf.org Partnership for Patient Safety www.p4ps.org/frame.html

Quality Health Care www.qualityhealthcare.org/ihi The Anesthesia Patient Safety Foundation www.gasnet.org/societies/apsf/ The Institute of Healthcare Improvement www.ihi.org/ The Leapfrog Group for Patient Safety www.leapfroggroup.org The National Quality Forum www.qualityforum.org The Quality Interagency Coordination Task Force (QuIC) www.quic.gov/index.htm VA National Center for Patient Safety www.patientsafety.gov

References 1. www.jointcommission.org/PatientSafety/UniversalProtocol/up_facts.htm 2. www.jointcommission.org/NR/rdonlyres/E3C600EB-043B-4E86-B04ECA4A89AD5433/0/universal_protocol.pdf 3. www.jointcommission.org/NR/rdonlyres/DEC4A816-ED52-4C04-AF8CFEBA74A732EA/0/up_guidelines.pdf 4. www.aorn.org/toolkit/pdf/Resources.pdf