Table 4Differences between NYSSIPP and the Universal Protocol

Section of NYSSIPPNYSSIPP comparisons to Universal Protocol (UP)
  • Not included in UP.
  • Detail required in scheduling (implant, equipment, no abbreviations).
  • Information received must be verified.
Consent documentation
  • Increased detail required (layman’s terms; spell out side/sites; no changes permitted after signatures obtained).
Pre-operative verification process
  • Multiple specific steps with increased detail in NYSSIPP.
  • Must take place before entering OR (exception detailed).
Pre-operative checklist
  • A pre-operative or pre-procedural verification checklist is required.
Marking & verifying the operative site
  • Images required to be present in OR, viewed by 2 individuals, and orientation of images confirmed.
  • Second time out for spine surgery including second image.
  • Alternative to patient marking in specific exceptions – special purpose wristband.
Time out
  • All work should cease during the “time out.”
  • All members of the team (surgical, anesthesia, nursing) must focus on the “time out.”
Required policy and procedure
  • The institutional policy and procedure must specify the actions to be taken when a discrepancy occurs at any step in the process.
  • Responsibilities must be more specifically defined.
Compliance monitoring
  • Compliance monitoring of NYSSIPP is an integral part of a facility’s performance improvement/quality assurance activities.
  • The role of monitoring and leadership in setting expectations is key.

NYSSIPP = New York State Surgical and Invasive Procedure Protocol; UP = Universal Protocol; OR = operating room

From: The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures

Cover of Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment)
Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment).
Henriksen K, Battles JB, Keyes MA, et al., editors.

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