Transcript universal protocol

Time Out
Universal Protocol
Revised December 2012 by S Folmer, MSN, MBA, CNOR, CGA
Reviewed December 2013 by D Rohrbaugh, RN
Correct Patient, Correct Procedure, Correct Position,
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Correct Site/Side, Correct Equipment
Why Should I Care?
This information is applicable to ANY area
that performs invasive procedures,
not just the surgical arena.
Universal Protocol is a Joint Commission
requirement as well as CMS and the World
Health Organization (WHO).
It is a standard of practice among multiple
nursing organizations.
Correct Patient, Correct Procedure, Correct Position,
Correct Site/Side, Correct Equipment
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WHY UNIVERSAL PROTOCOL?

The process of identifying the
patient and procedure in order to
prevent errors of wrong patient,
wrong site, wrong surgery.

The Joint Commission has
identified the prevention of these
errors as one of our National
Patient Safety Goals (NPSG)
It is the responsibility of health care providers
to ensure the safety of all patients
undergoing invasive procedures.
Correct Patient, Correct Procedure, Correct Position,
Correct Site/Side, Correct Equipment
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Universal Protocol Includes
Conduct a pre-procedure ‘Time out’
verification:

Correct patient

Correct procedure

Correct site

As applicable, any implants

Including the patient in the verification process when possible


Identify items that must be available for the procedure and use a
standardized list to verify availability
Missing information or discrepancies must be addressed before
starting the procedure
Correct Patient, Correct Procedure, Correct Position,
Correct Site/Side, Correct Equipment
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Pre-Procedure Verification
Prior to a patient undergoing any invasive
procedure, the nurse will obtain the
pre-procedure checklist and assemble all of the
elements listed to provide the information
needed by the physician.
1. Verify the presence of relevant documentation:

Physician Orders

Informed consent

History & physical

Nursing Assessment

Pre-anesthesia assessment as applicable

Department specific invasive procedure assessment checklist
Correct Patient, Correct Procedure, Correct Position,
Correct Site/Side, Correct Equipment
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Pre-Procedure Verification
cont’
2.
3.
4.
Labeled diagnostic and radiology test results

Radiology images or scans

Pathology or biopsy reports
Any required supplies should be immediately available
in the room where the procedure will be done

blood products

Implants

devices and/or special equipment of the procedure

Medications ordered by the physician
Match the items that need to be available in the
procedure area to the patient
Correct Patient, Correct Procedure, Correct Position,
Correct Site/Side, Correct Equipment
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Pre-Procedure Verification
cont’

The above documents along with patient/family identification
must indicate the same type and site/side of invasive
procedure

The care provider taking the initial posting of procedure will
verify patient name, DOB, and procedure site and side.

The patient care provider will identify the patient and verify the
invasive procedure and site/side in the department where the
procedure is being performed

The patient care provider will ensure the completion of the preprocedure assessment and that all pre-procedure
requirements are on the patients chart.
Correct Patient, Correct Procedure, Correct Position,
Correct Site/Side, Correct Equipment
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PREPROCEDURE
SIGN-IN
TIME-OUT
SIGN-OUT
CHECK-IN
Example of
Checklist
Used FOR
ANY
INVASIVE
procedure
In Holding Area
Before Induction of Anesthesia
Before Skin Incision
Patient/patient representative
actively confirms with
Registered Nurse (RN):
RN and anesthesia care provider
confirm:
Initiated by designated team member
Identity □ Yes
Procedure and procedure site
□ Yes
Consent(s) □ Yes
Site marked □ Yes
□ N/A
by person performing the
procedure
Confirmation of: identity,
procedure, procedure site and
consent(s) □ Yes
Site marked □ Yes □ N/A
by person performing the
procedure
Introduction of team members □ Yes
Patient allergies □ Yes □ N/A
RN confirms presence of:
History and physical □ Yes
Preanesthesia assessment
□ Yes
Diagnostic and radiologic test
results □ Yes
□ N/A
Blood products
□ Yes
□ N/A
Any special equipment,
devices, implants
□ Yes
□
Include in Preprocedure
check-in as per institutional
custom:
Beta blocker medication given
(SCIP) □ Yes
□ N/A
Venous thromboembolism
prophylaxis ordered (SCIP)
□Yes
□ N/A
Normothermia measures
(SCIP) □ Yes
□ N/A
N/A
Difficult airway or aspiration
risk?
□ No
□ Yes (preparation confirmed)
Risk of blood loss (> 500 ml)
□ Yes □ N/A
# of units available ______
Anesthesia safety check
completed
□ Yes
Briefing:
All members of the team have
discussed care plan and
addressed concerns
□ Yes
Before the Patient Leaves the
Operating Room
RN confirms:
All other activities to be suspended
(unless a life-threatening emergency)
All:
Confirmation of the following: identity,
procedure, incision site, consent(s)
□ Yes
Site is marked and visible □ Yes
□
N/A
Relevant images properly labeled and
displayed □ Yes
□ N/A
Any equipment concerns?
Anticipated Critical Events
Surgeon:
States the following:
□ critical or nonroutine steps
□ case duration
□ anticipated blood loss
Anesthesia Provider:
□ Antibiotic prophylaxis within one hour
before incision □ Yes
□ N/A
□ Additional concerns?
Scrub and circulating nurse:
□ Sterilization indicators have been
confirmed
□ Additional concerns?
Correct Patient, Correct Procedure, Correct Position,
Correct Site/Side, Correct Equipment
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Name of operative procedure
Completion of sponge, sharp, and
instrument counts □ Yes
□ N/A
Specimens identified and labeled
□ Yes
□ N/A
Any equipment problems to be
addressed? □ Yes
□ N/A
To all team members:
What are the key concerns for
recovery and management of this
patient?
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
April 2010
MARKING THE PROCEDURE
SITE/SIDE
Per Joint Commission & World Health Organization (WHO): “At a minimum, mark the
site when there is more than one possible location for the procedure and when
performing the procedure in a different location could harm the patient.”
Mark the procedure site before the procedure is performed and if possible, with the
patient involved. The patient care provider will ask the patient and/or family what
procedure is to be done and on what site/side. **DO NOT ASK A YES OR NO
QUESTION
The licensed independent practitioner (LIP) or other provider who is medical staff
credentialed to perform the intended surgical or non-invasive procedure will mark the
site/side. This LIP or other provider must be involved directly in the procedure and will
be present during the procedure.
Correct Patient, Correct Procedure, Correct Position,
Correct Site/Side, Correct Equipment
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MARKING THE PROCEDURE
SITE/SIDE
The LIP may delegate site marking to an individual who is
permitted by the organization to participate in the procedure
and has the following qualifications:

Medical resident who is being supervised by the LIP performing
the procedure

A licensed individual who performs duties requiring collaborative
agreement with the LIP performing the procedure

Advanced Practice Nurse

Physician Assistant
Correct Patient, Correct Procedure, Correct Position,
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Correct Site/Side, Correct Equipment
MARKING THE PROCEDURE
SITE/SIDE
AT THE BEDSIDE: When patient / family identifies the
site/side, the LIP will use a single use sterile skin
marker and print their first, middle, and last initial on the
surgical site

Focus on cases involving right / left distinction

Multiple structures ie: fingers

Levels ie: spine

Facial site procedures may be marked with a bandaid with “R” or “L” marked on the band aid
Correct Patient, Correct Procedure, Correct Position,
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Correct Site/Side, Correct Equipment
MARKING THE PROCEDURE
SITE/SIDE

The method of marking the site and the type of mark is
unambiguous and is used consistently throughout the
hospital.

The mark is made at the procedure site and is
sufficiently permanent to be visible after skin preparation
and draping.

A written alternative process is in place for patients who
refuse site marking or when it is technically or
anatomically impossible or impractical to mark the site
Correct Patient, Correct Procedure, Correct Position,
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Correct Site/Side, Correct Equipment
SITE MARKING: Not Needed For…

Procedures on a single organ or site ie: C-section

Procedures on teeth

Premature infants for whom the mark may cause a permanent tattoo

Procedures treating a lateralized internal organ, whether percutaneous
or through a natural orifice

Interventional procedures where the insertion site is not pre-determined
ie: cardiac catheterizations and pacemaker insertion

But these procedures still require confirming patient identification
and correct procedure prior to initiation of the procedure. The
patient care provider will ask the patient and/or family what
procedure is to be done and on what site/side.
DO NOT ASK A YES OR NO QUESTION.
Correct Patient, Correct Procedure, Correct Position,
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Correct Site/Side, Correct Equipment
TIME OUT PROCESS

Conducted immediately before starting any invasive procedure

Involves all immediate members of the procedure team

Team members agree, at a minimum, on the
following:

Correct patient identity (full legal name and date of birth)

Correct site as marked or described if marking
is not indicated

The procedure to be done

The healthcare provider (a nurse in most instances) will consistently be the designated
member of the team to conduct the “time out” process. In the absence of this person the
LIP will be responsible for conducting the “time out” process

The invasive procedure will not proceed until complete verification of all issues listed
have been confirmed during the Time Out process
Correct Patient, Correct Procedure, Correct Position,
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Correct Site/Side, Correct Equipment
TIME OUT PROCESS
When 2 or more procedures are being
performed on the same patient, and the
person performing the procedure
changes, a TIME OUT must be
performed before each procedure is initiated.
Example: a time out must be done prior to spinal
anesthesia as well as immediately prior to the surgical
procedure itself.
Correct Patient, Correct Procedure, Correct Position,
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Correct Site/Side, Correct Equipment
TIME OUT PROCESS
Documentation

Verification of invasive procedure and site/side will be
documented in the following areas:
 Surgical / Procedural Safety Checklist found in EPIC and use
FormFast for downtime
 Nurses’ notes or patient care provider notes
 Anesthesia or sedation record (as applicable)
 Licensed Independent Practitioner’s post procedure note
Correct Patient, Correct Procedure, Correct Position,
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Correct Site/Side, Correct Equipment
Emergency Situations

In the event of an emergency invasive
procedure, the patient care provider will
document in the nurse’s notes or the
patient care providers notes that the
procedure is an emergency and how the
procedure site/side has been identified
(i.e. X-rays, diagnostic tests.) The
procedure site/side will be marked as
above.
Correct Patient, Correct Procedure, Correct Position,
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Correct Site/Side, Correct Equipment
PATIENT REFUSAL
If the patient / family refuses site marking:

Patient care provider assesses reason and notifies physician
performing procedure - document

Procedure is delayed and time-out is altered until additional
patient education can be provided regarding importance of site
marking for patient safety - document

Verbal agreement to proposed
procedure must be reaffirmed –
document

Proceed with time-out process
Correct Patient, Correct Procedure, Correct Position,
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Correct Site/Side, Correct Equipment

We hope this course has been both
informative and helpful. Review this course
until you are confident about your
knowledge of the material presented.

Please take the post test to complete this
course. Thank You.
Correct Patient, Correct Procedure, Correct Position,
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Correct Site/Side, Correct Equipment