JCAHO Protocol: Conduct A Preprocedure Verification Process

1116 Words 5 Pages
Register to read the introduction… JCAHO found- Medical records of patients undergoing procedure were not complete. To address all of these findings we need to look at our current protocol and make adjustments so it is in line with current JCAHO requirements. Our current protocol is broken down into the following subsections: Policy, Preoperative/Preprocedure Verification Process, Marking the Operative/Invasive Site, Patient Procedure and Site Verification, Time-Out Procedures and finally Bedside Procedures. In the following sections the JCAHO standard will be addressed with the corrective actions indicated to our protocol. The first JCAHO focus that will be addressed in relation to our protocol is UP.01.01.01: Conduct a preprocedure verification process. The part of our protocol that deals with this area is Preoperative/Preprocedure Verification Process. While policies are a general guideline for procedures this protocol needs to have more clarification. According to UP.01.01.01, not only do we need to address the procedure site on the correct patient, but also we need to identify the correct items that will be need for the procedure. The following needed to be included in the protocol and these …show more content…
It should be stated in our protocol what to do if a patient refuses to be marked for the procedure. a. A written form should be available for this occurrence. 4. There should be further exceptions to site marking. These exceptions will include: a. Internal organs b. Interventional cases for which the site may change. c. Teeth d. Premature infants
The third JCAHO focus area is UP.01.03.01: A time-out is performed before the procedure. The part of our protocol that relates to this standard is: Time-Out Procedures. When the graph showing hospital wide time-outs is analyzed, it is obvious that we are not attaining the one hundred percent goal. While there are some aspects of the protocol that are correct, the following changes need to be made to our protocol:
1. A time-out must be called immediately before starting the invasive procedure.
2. It is standardized by the hospital.
3. It is designated by a member of the team.
4. It involves all members of the procedure team. a. This is ALL the participants who will be participating from the beginning. 5. If two or more procedures are being performed, a time-out will happen before each one. 6. Document the completion of the

Related Documents