GUIDELINES FOR VERIFICATION OF PATIENT/PROCEDURE

AND SITE OF PROCEDURE/SURGERY

February, 2004

Purpose:

The evidence-based guidelines listed below were developed by the Colorado Health and Hospital Association to form the basis for the development of hospital specific policies, procedures, protocols, and education programs.

Objective:

Standardize the surgical/invasive procedure site verification process to ensure correct patient, correct surgery/procedure, correct site, and correct side/level. Verification, side and /or site marking and "time out" procedures should be as consistent as possible across the organization.

Guidelines:

Pre-operative verification process

1. The patient and procedure verification portion of these guidelines will be applied in all areas of the hospital that routinely perform procedures. Specifically this includes operating suites, interventional radiology departments, cardiac catheterization suites, endoscopy, special procedure units, outpatient surgery suites and labor and delivery departments.

2. The verification process for site and/or side of the procedure described in these guidelines, will apply only to all procedures involving right/left distinction, levels, or multiple structures (fingers, toes, lesions).

3. The site/side verification process excludes procedures that are being performed in life threatening or emergent situations such as in the emergency department or labor and delivery, procedures done through or immediately adjacent to a natural body orifice, dental procedures, mid-line sternotomy, C-section, laparotomy and laparoscopy and cardiac catheterization (catheter insertion site is not predetermined).

4. Anyone on the procedure team has an equal voice and responsibility to identify and voice concerns related to inconsistencies and discrepancies found during the course of the verification process.

5. All procedures involving right/left distinction will be scheduled by the hospital with either right or left designation.

6. At the time of scheduling and admission for the procedure, hospital staff will verify patient identity, operative and other invasive procedure to be performed, (hereafter called "procedure") and side and/or site of procedure. This verification will occur also anytime the responsibility for care of the patient is transferred to another caregiver.

7. All informed consents for procedures involving right/left distinction will include right or left spelled out on the consent form.

8. Before the procedure begins and before the patient leaves the preoperative area or enters the procedure/surgical room, the following will be verified by a member of the surgical/procedure team:

a) Check the accuracy of the patient identification band

b) Confirm the History and Physical for procedure and site

c) Confirm the hospital schedule for procedure and site

d) Confirm the consent for procedure and site

e) Confirm with all relevant imaging studies for site

f) If the patient is scheduled for multiple procedures by multiple practitioners, all items must be checked for each procedure.

g) If any of the above fails to match, the process will be halted until verification is accurate.

Marking the procedural site

1. Before the procedure, the hospital care provider, in collaboration with the patient/designated representative, will identify the procedure to be performed and the side and/or site of the procedure.

2. When at all possible, the patient/designated representative will mark the side and/or site of the procedure with a "Yes" with the hospital care provider present.

3. If the patient is unable, the hospital care provider will mark the side and/or site of the procedure as described above, with the patient/designated representative present.

4. The non-operative side and/or site will not be marked.

5. The person performing the procedure will verify the procedure and side and/or site with the patient/designated representative and mark the site of the incision with their initials. The mark must be visible after prepping and draping.

6. All marks should be made using a marker that is sufficiently permanent to remain visible after completion of the skin prep.

7. A defined procedure should be in place for patients who refuse site marking.

8. Special intraoperative radiographic techniques should be used for marking the exact vertebral level/s.

9. The anesthesia provider will verify the procedure and side of the procedure with the patient/designated representative and document in the anesthesia record.

"Time Out" immediately before starting the procedure

1. The "time out" will be conducted in the location where the procedure will be performed, immediately prior to beginning the procedure and after draping has occurred.

2. The entire procedural team, including the person performing the procedure, will pause and take a "time out" and verbally verify the following:

a) Patient identification;

b) Procedure to be performed;

c) Side and/or site of incision;

d) Correct patient position;

e) Availability of correct implants and any special equipment or special requirements.

3. The "time-out" described above, will consistently be initiated by a designated member of the procedural team and the procedure will not be started until any questions, concerns or discrepancies are resolved.

It is recommended that the entire verification process be documented including names of participants present for the "time-out".

Evidence Considered:

Resources utilized to develop these guidelines include the following:

* American College of Surgeons: Statement on Correct Site Surgery

* American Association of Orthopaedic Surgeons: Advisory Statement on Wrong Site Surgery

* North American Spine Society: Prevention of Wrong-Site Surgery, Sign, Mark and X-ray (SMAX)

* Joint Commission on Accreditation of Healthcare Organizations: 2004 National Patient Safety Goals-Universal Protocol
* Joint Commission Perspectives February, 2004: JCAHOÕs Universal Protocol Released to Widespread Endorsement

* The Association of Perioperative Registered Nurses (AORN): Position Statement on Correct Site Surgery

Contributing and reviewing organizations

* CFMC

* COPIC

* CNA

* AORN

* Colorado Medical Society

* Colorado Pharmacy Society

* CHHA Quality Professionals

* Multiple Colorado Hospitals

* Colorado Patient Safety Coalition