Criterion 5.3.4 PROCEDURE COMPLIANCE

 Criterion 5.3.4

Processes to ensure the right patient, right procedure, and right side for patients undergoing surgery/medical procedures are established and implemented.

1) Main Thoughts:

a) The occurrence of injuries and unexpected events can be caused by the wrong person, the wrong procedure, the wrong side of invasive procedures or actions on the patient.

b) The Community Health Center must determine operative procedures, invasive procedures and procedures which include all actions involving cuts/incisions or punctures, tissue extraction, tooth extraction, implant installation and other invasive actions or procedures that fall under the authority of the Community Health Center as a level health service facility. First.

c) Puskesmas must develop a system to ensure the correct patient, correct procedure, and correct side when carrying out actions by implementing a general protocol (universal protocol) which includes:

(1) verification process before action is taken; Marking of the side where the action/procedure will be carried out; And

(2) time out which is done immediately before the procedure begins.

d) The verification process before carrying out the action aims to verify the correct person, correct procedure, correct side, ensuring that all documents, approval of medical action, medical records, results of supporting examinations are available and labeled, ensuring that medicines, intravenous fluids, and if any are available The necessary blood products, medical devices or implants are available and ready for use.

e) Marking of the side that will receive the action/procedure is made by involving the patient if possible and is done with signs that are immediately recognizable and not confusing. Marking must be done uniformly and consistently. Marking is performed on all organs that have laterality (right versus left, such as one of two limbs, one of a pair of organs), multiple structures (such as fingers, toes, or lesions), or multiple levels (spine). For procedures at the dental clinic, such as tooth extraction, markings, if necessary, are carried out using dental x-rays or odontograms. Marking must be carried out by the operator/person who will carry out the procedure and the entire procedure and remain with the patient during the procedure.

f) Side marking can be performed at any time before the procedure begins as long as the patient is actively involved in side marking and marking. There are times when patients are in a situation where it is not possible to participate, for example in pediatric patients or when the patient is not competent to make decisions about health care.

g) A break (time out) is an opportunity to answer all unanswered questions or straighten out any confusion. The break is held at the location where the procedure will be performed, just before starting the procedure, and involves the entire team that will be performing the surgical or invasive procedure.

2) Assessment Elements:

a) Marking of the side of the operation/medical procedure is carried out consistently by the service provider who will carry out the action in accordance with the established policies and procedures (R,O,W,S).

b) Verification is carried out before surgery/medical procedures to ensure that the procedure has been carried out correctly (D, O, W).

c) There is a time out before surgery/medical procedures to ensure all questions have been answered or to straighten out any confusion (O,W).