Universal Protocol Policy Changes to Keep Our Patients Safe
Following a two-year process involving feedback and support from a multidisciplinary team of clinicians, a new networkwide policy will go into effect March 30, 2021 to prevent wrong side wrong site surgery.
At Hackensack Meridian Health, One Team for Safety is committed to ZERO preventable harm, with focus on a preoccupation with failure. To get there, we implement evidence-based policy improvements. Variation is the enemy of safety, and by standardizing our practices we can reduce human error.
This new networkwide policy will result in a standardized:
- Pre-procedure/pre-operative process to prevent wrong side wrong site surgery.
- “All EPIC” process.
- Site marking based on best practice.
- Evidence-based “alternative” to site marking.
Specific policy changes to current practice will include:
- Refusal of surgical site marking will result in the cancellation of a procedure.
- Network site marking will be the initials of the practitioner.
- Alternative to site marking will be a banding procedure.
- Pre-Procedure/Pre-Operative Verification process to be documented in EPIC for ALL patient care areas.
The new networkwide policy will go into effect on Tuesday, March 30, 2021. Impacted team members will receive notice of an assigned learning module in February 2021, which will need to be completed prior to the March 2 go live. Note: private physicians will need to access the assigned learning module through Maestro.