that gives you access to downloadable
education.
4. Patience must be practiced.
resources and materials for doing quality
Implementation takes time to co-opt early and
improvement in your facility. Compare
late adopters — in our experience, about 6
your current site-marking protocols to the
months.
Joint Commission's suggestions (see
So what we're really talking about isn't motiva-
"Reduce Wrong-Site Risks" on page 14).
tion or encouragement, it's implementation sci-
Do you notice any room for improvement?
ence — what you need to do to create an envi-
If so, you might face some hurdles.
The biggest barrier might be all the
ronment that encourages compliance with behavior change, across an organization. This science
tracking and paperwork required to know
involves the 4 components described above. One
if change is actually happening at the front
more thing: Although a degree of patience is key,
line. Before beginning our policy improve-
so are follow-up and reinforcement. Because if
ments, for example, we collected data for
you know there's a policeman patrolling a particu-
30 days just so we could spot errors. After
lar length of highway, you proceed with caution.
making changes, we tracked data for
— John R. Clarke, MD
every procedure another 30 days, to validate the implementation of new practices.
Dr. Clarke (jclarke@ecri.org) is the editor of the
Pennsylvania Patient Safety Advisory, clinical
director of the Pennsylvania Patient Safety
Authority and a professor of surgery at Drexel
University.
Although it's a lot of work, trust me: It'll
all feel worthwhile when you reach full
compliance.
ON THE WEB
One of the facilities I now manage
Pennsylvania Patient Safety Authority
• 21 Recommendations and Barriers
to Preventing Wrong-Site Surgery
bit.ly/UGH9DT
• Wrong-Site Surgery Toolkit
bit.ly/nTXLxH
recently used the TST to do its own quality improvement project. That facility has
never had a wrong-site surgery, but the
staff recognized the importance of assessing process-related risks and redesigning
those processes to further reduce the
chance of a wrong event's occurrence.
J A N U A R Y 2013 | S U P P L E M E N T
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