An important component of fostering a culture of patient safety in a health care setting is having all health care providers adopt common procedures and safeguards to decrease the risk of harm to patients [7
]. This is the goal of the Universal Protocol that was implemented nationwide in 2004 to help prevent medical injuries and deaths caused by wrong-site, wrong-procedure or wrong-identity of a patient during surgery or other invasive procedures, including pathologist performed fine needle aspirations [8
Like most hospitals, the Emory University Hospital has implemented this Protocol and has put into place a policy and process for clinicians, including pathologists, to follow. The first step is to verify the patient's identity using at least two patient identifiers, which can be the patient's name, birth date or medical record number. Then the intended procedure also is confirmed by checking the procedure consent form, the history or progress notes, nursing assessment and, if applicable, the procedure/surgical operating room schedule (Table ) [4
The second step is that the procedure site must be properly marked to identify the area of the patient's body that will undergo the procedure before an incision is made (Table ) [4
]. For example, if a patient is having a fine needle aspiration of the left breast, the pathologist would write "YES" on the patient's left breast area to distinguish the site from the right breast. The patient is also an integral part of this safety practice and participates by verifying his or her identity as well as confirming correct procedure, correct side and site.
Before the procedure starts, a third step or "time out
" is initiated by the physician conducting the procedure to give all members of the clinical team an opportunity to perform a final verification of the correct patient, correct procedure, correct side, correct site, correct patient position and availability of any special equipment or requirements that are needed for the fine needle aspiration procedure (Table ) [4
JCAHO requires that pathologist performed fine needle aspiration procedures adhere to the rules of the Universal Protocol including the implementation of "time out" for these procedures. The "time out" procedure also needs to be documented for JCAHO inspectors to review. This can be done either by documenting "time out" as a note in the patient's medical file, which is retained as a hard copy in the patient's medical records. Alternatively, "time out" can be also be documented by incorporating it as part of the fine need aspiration report. A text reading out as "The patient is identified using two identifiers. The site of the fine needle aspiration procedure is also verified with the patient. The lesion is palpated, correctly identified, and marked with ink during time out completion", incorporated in the Fine needle aspiration report will conform completion of "time out" for the procedure.
At our institution, the Universal Protocol has been implemented for all pathologist performed fine needle aspirations. This has been in effect since January 01, 2005. In the years 2005 and 2006, a total of 1,779 and 2,079 fine needle aspirations, respectively, were performed by pathologists. In reviewing this data, no errors were detected based on wrong person or wrong site. In summary, at our institution, the implementation of the Universal Protocol has been successful, since conforming to it necessitates that appropriate time be allocated for its compliance and hence prevent any error in patient identity or site identification, for patients about to undergo a fine needle aspiration.