The Correct Patient, Correct Site and Correct Procedure Policy and Guidelines for WA Health Services (2nd Edition)

The Correct Patient, Correct Site and Correct Procedure Policy and Guidelines, released by the WA Council for Safety and Quality in Health Care (‘the Council’) and the Office Safety and Quality in Health Care in March 2005 have been updated and re-issued.  The updated Correct Patient, Correct Site and Correct Procedure Policy and Guidelines for WA Health Services supersedes Operational Circular OP 1933/05.

The revised and updated Correct Patient, Correct Site and Correct Procedure Policy and Guidelines for WA Health Services and associated resource materials may be accessed on the Office of Safety and Quality in Health Care (OSQH) website at the following address: http://www.health.wa.gov.au/safetyandquality/programs/correct.cfm

THE FIVE STAGES OF THE ‘CORRECT PATIENT, CORRECT SITE AND CORRECT PROCEDURE’ POLICY AND GUIDELINES
The updated Correct Patient, Correct Site and Correct Procedure Policy and Guidelines for WA Health Services provide a standardised approach for WA health professionals to prepare patients for surgical, anaesthetic, radiology and oncology procedures or medical treatment involving invasive interventions.

The definition of ‘correct site’ includes identifying the correct side (ie left or right) and the correct and precise anatomical location of the surgery or procedure, eg anatomical location, specific vertebral body, or finger.

The Correct Patient, Correct Site and Correct Procedure Policy and Guidelines for WA Health Services outline the five steps (see below) that must be taken by the clinical team to ensure the correct surgery/procedure is performed on the correct patient, at the correct site, and if relevant, with the correct implant.

1. Ensure that the patient’s consent has been gained for the treatment or procedure. In Western Australia, a medical practitioner is legally responsible for ensuring consent to treatment has been adequately obtained. Where a medical practitioner recommends or advises that a patient undergo treatment, they are responsible for providing sufficient, appropriate information and advice to the patient to enable him/her to make their own informed decision to undergo the treatment. 
2. Mark the site of the surgery or invasive procedure. The site of the operation or an invasive procedure must be marked indelibly by the person in charge of the procedure or a delegated staff member who has been fully briefed about the operation or procedure.
3. Confirm the patient’s identity. Prior to the patient receiving any medication that could affect their cognitive function, members of the clinical team should ask the patient to state (not confirm) their full name, date of birth, the reason for the procedure and the site of the procedure to be performed.  Staff must check the patient’s responses against the patient’s ID band, consent form and other information provided in the patient’s clinical record.
4. Take a ‘team time out’ in the operating theatre, treatment or examination area. When the patient arrives in the operating theatre or treatment room, and prior to the procedure beginning, staff must verbally confirm through a ‘team time out’: the presence of the correct patient, the correct type of procedure to be performed, that the correct site has been marked, and availability of the correct implant, where required.
5. Ensure that correct and appropriate diagnostic images are available.  If imaging data are used to confirm the site of procedure, two or more members of the team must confirm that the diagnostic images have been properly labelled and are for the correct patient.

The Correct Patient, Correct Site and Correct Procedure Policy and Guidelines for WA Health Services represent the minimum standard of care that is expected from all WA clinicians and WA public hospitals.  It is expected that all Area Health Services will ensure that the five-step process outlined in the correct patient, correct site, correct procedure guidelines are implemented and utilised in all surgical, anaesthetic, medical, radiology, oncology and endoscopy specialties. 

REQUIRED ACTION IN THE EVENT OF A WRONG PATIENT, WRONG PROCEDURE OR WRONG SITE INCIDENT
Procedures involving the wrong patient, wrong site or wrong procedure are reportable sentinel events.  It is a Department of Health requirement that a sentinel event reporting form is completed and forwarded to the Department of Health within seven (7) working days of the wrong patient, wrong procedure or wrong site incident occurring.  Please refer to the Office of Safety and Quality in Health Care website for more information on the sentinel event reporting and investigation process: www.health.wa.gov.au/safetyandquality/

FURTHER INFORMATION
All enquiries about the Correct Patient, Correct Site and Correct Procedure Policy and Guidelines for WA Health Services should be directed to the Office of Safety and Quality in Health Care on (08) 9222 4080 or e-mail: safetyandquality@health.wa.gov.au

Dr Neale Fong
DIRECTOR GENERAL
DEPARTMENT OF HEALTH