Dear Administrator - New York State Surgical and Invasive Procedure Protocol (NYSSIPP)
October 19, 2006
The incidence of wrong patient, wrong site/side and wrong invasive procedures continues to occur with alarming frequency. Although initially considered relevant to the operating room, wrong patient, wrong site/side and wrong invasive procedures occur at least three times more frequently outside the O.R. according to evidence based information collected by the New York Patient Occurrence Reporting and Tracking System NYPORTS.
The New York State Department of Health is instituting a new initiative to assure that the correct procedure is performed on the correct patient at the correct site or side. I would like to share with you the New York State Surgical and Invasive Procedure Protocol for Hospitals, Surgery Centers and Individual practitioners.
In December of 2005, a panel of statewide and national experts convened to review the available data from NYPORTS and to assess the continued incidence of wrong patient, wrong site/side and wrong invasive procedures. The Panel considered the recommendations of the Pre-Operative Protocols for Hospitals, Ambulatory Surgery Centers and Individual Practitioners shared by the NYSDOH in January of 2001, and the Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol published in 2003.
A revised protocol was developed using these documents as a starting point and incorporating current, relevant medical literature, and documented lessons learned from actual occurrences submitted to NYPORTS, and the collective expertise of the 26 member panel. The revised protocol, endorsed by me, will be an expected minimum standard of care for all Article 28 facilities. It may be added to or enhanced to meet individual specialty needs and circumstances.
As we are increasingly aware of the fact that invasive procedures are performed throughout a facility and are not limited to the operating room, it is expected that these measures be utilized in all areas of a facility where invasive procedures are performed (e.g., including – but not limited to - special procedure room, bedside, radiology, emergency room).
It is imperative that we work together in a standardized fashion to address this preventable event. We firmly believe that this initiative will enhance patient safety and reduce medical and surgical errors.
Thank you for your cooperation in this very important matter.
Sincerely,Antonia C. Novello, M.D., M.P.H., Dr. P.H.
Commissioner of Health