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Patient Safety

• The exact dates to stop taking any aspirin products or diabetic medications;

• Which lab tests must be performed, if applicable; and

• Whether other services (e.g., ECG, X-ray or phar- macy) are applicable.

All of this information is then compiled – legibly – into an instruction sheet clearly labeled with the warning, “Failure to follow the instructions can result in your procedure being cancelled.” The patient signs the instruc- tions using a digital signature capture pad and is given a printed copy of the signed instructions.

A note documenting the exact date and time that the instructions were provided to the patient automatically is posted to the patient’s medical record in the EHR. An image of the signed instruction document automati- cally is posted to the facility’s document management system. This automated process ensures that providers can confi rm immediately and easily that patients have received all necessary instructions.

Obtaining positive results

In 2009, a total of 1,152 sets of pre-procedure in- structions were produced with GCVHCS’ automated informed consent application and saved electronically in the EHR. In 2010, the number rose to about 1,857. Since implementing this process, GCVHCS facilities have seen a signifi cant increase in the number of patients fully prepared for their procedures. Not surprisingly, they also have experienced a corresponding decrease in the number of procedure cancellations, missed appoint- ments, and missed lab work. During its survey of the Pen- sacola facility, The Joint Commission expressed approval of the clearly documented, personalized process for supplying pre-procedure instructions.

Bunny Isgett-Lynn, BSN, RN, is clinical application coordinator for the VA Gulf Coast Veterans Health Care System in Biloxi, Miss.

For more information on Dialog Medical solutions:

Nursing staff appreci- ate that they no longer are questioned about the in- structions provided. All of the “dos” and “don’ts” discussed with patients are

clearly documented in the chart. Should any questions arise later – whether for patient care or legal reasons – the information is legible, dated and signed. By using an automated system to facilitate the distri- bution of pre-procedure instructions, GCVHCS also no longer has a cache of diffi cult-to-update paper documents stashed away in cabinets. Instead, copies of instructions can be printed and distributed as many times as needed, which goes a long way toward the mission objective of patient record portability legislation.

26 March 2011

In addition, GCVHCS has further increased the util- ity of the application by tailoring it to automate other key processes. Among them: • Advance directives. These documents are electroni- cally signed and posted to the record in the same manner as pre-procedure instructions.

Schedule II narcotics distribution. The pharmacy uses a template to capture electronic patient signatures acknowledging receipt of Schedule II narcotics.

Valuables inventory. Emergency department staff take inventory of any valuables (jewelry, cash, etc.) that arrive with patients. Patients electronically sign the checklist, which is then posted to the electronic record. This use of the application has helped GCVH- CS avoid frivolous legal claims alleging lost or stolen items.

Transforming patient care GCVHCS was lucky in one respect: The conversion from a paper-based to an automated pre-procedure process quickly garnered the support of all involved. Collaboration among surgeons, nursing staff, IT staff and even the application vendor was manifest from the outset. This likely was due, at least in part, to previous familiarity and comfort with the AICA. Other facilities considering a similar process transformation should con- sider the involvement of all constituencies – beginning with the planning process – to ensure staff buy-in. For GCVHCS, however, the application has become an essential tool to document that patients have received the right instructions, for the right procedure and at the right time. It is a tool that engages veterans in their own care, leading to more positive outcomes. From accountable care to patient-centered care, many national healthcare reform efforts emphasize the critical importance of empowering patients in their own healthcare decisions. By signing that they have received patient-specifi c and procedure-specifi c pre-operative instructions, patients at GCVHCS now shoulder a right- ful piece of responsibility for their care. Individualization of the process reinforces providers’ discussions, engages patients in their care and increases their odds of having a good experience and positive outcome.


1. Hathaway D. Effect of preoperative instruction on postoperative outcomes: a meta-analysis. J Nurse Res. 1986;35(5):269-75.

2. Henderson BA, et al. Incidence and causes of ocular surgery cancellations in an ambulatory surgical center. J Cataract Refract Surg. 2006;32(1):95-102. 3. Pletta C, et al. Incidence and causes of ocular surgery cancellations in an ambulatory surgical center. J Nucl Med. 2008;49(Supp 1):426P.


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