MAPS Surgery Scheduling and Verification Pilot Fact Sheet
After an initial visit with a patient, a surgeon hands the patient's record to a nurse asking that surgery be scheduled for the right knee. The nurse, in the midst of an extremely busy day does not find time to schedule the surgery until the end of the shift. She schedules surgery for the patient’s left knee after noting problems in the chart with the left knee. On the day of the surgery, the consent form reflects that the surgery was scheduled for the left knee and the patient does not speak up to correct the problem, the chart isn’t reviewed for verification, and the radiology reports are not available in the OR. Moments later the surgery is underway on the wrong knee.
Correcting these problems in the surgery scheduling and verification process may reduce future mistakes. Careful attention is required during each of the many steps leading up to surgery in order to prevent a wrong-site surgery, surgery on the wrong-patient, or the wrong surgery. Starting with the patient being scheduled for surgery, there are numerous opportunities to make sure that the correct procedure is being performed on the correct patient.
What is the Surgery Scheduling and Verification project?
The Minnesota Alliance for Patient Safety (MAPS) Surgery Scheduling and Verification project is an effort to increase the accuracy of information communicated between clinics and hospitals or surgical centers in the surgery scheduling process. In 2009, MAPS solicited help from the hospital, clinic, and ambulatory surgical center community to outline a uniform process for scheduling surgery and reconciling essential patient information prior to surgery. The stakeholder group also identified key check-points leading up to surgery, essential source documents, and a verification process using source documentation at the surgical facility.
The stakeholder process is the basis for the Surgery Scheduling and Verification pilot project. MAPS is currently pilot testing this standardized process in facilities in Minnesota for ease of implementation and to evaluate its impact on medical errors or near misses and on communication between settings.
How could participation in the Surgery Scheduling and Verification pilot project benefit our organization?
This project could be an opportunity to harness the strength of collaboration, build relationships across health care settings, and optimize patient safety and improve patient care. Participants would work collaboratively across health care settings to develop a plan to implement the “key elements* of the process for invasive procedure scheduling. MAPS would provide education, tools, technical assistance, resources, and an interactive forum to facilitate your organization implementation.
What would participation in the pilot entail?
Participation would engage clinic and surgical-facility staff and clinicians in improving patient safety.
· Clinicians: Clinician leadership and commitment is essential. The clinician performing the procedure completes the “Critical Components” on the scheduling form prior to seeing next patient and if the “Critical Components” are not completed by the clinician the procedure is not scheduled.
· Schedulers: Clear and accurate communication is critical. The surgery scheduling form is used to guide the scheduling process and a “read back” of the procedure “Critical Components” is preformed to confirm accuracy.
· Source documents: Comprehensive and timely source documentation is imperative. Source documents (informed consent document, physician order, laterality/location, diagnostic studies) must be sent to the hospital/surgical center where the procedure is to be performed at least 24 hours in advance of the procedure.
· Verification: Engaging everyone in the verification process is key. The procedure verified when scheduled, against source documents the day before and the day of surgery, and as the procedure begins.
Why we need your support
Our organization will be piloting this project and we need you support and engagement. Our efforts to improve safety must occur along the continuum of health care. This pilot is an opportunity to collaborate with our colleagues in other health care settings to insure patients are safe while in our care.
For questions please feel free to contact XXXX at (phone) number or