The housewide policy and procedure for Universal Protocol: Patient Procedure Verification Site Marking and Time-Out has been revised to align with 2015 National Patient Safety Goals. Physicians at Surgical Governance as well as the Medical Executive Committee had input into this work. This policy applies to all providers performing procedures and is intended to prevent wrong patient, wrong procedure and wrong site occurrences. The policy applies to any invasive procedure, regardless of setting or who is performing the procedure — operating room, inpatient floor, outpatient clinic, emergency department, etc.
The policy states that the professional performing the procedure will mark the site for all invasive procedures in the preprocedure setting. For cases in which it is technically or anatomically impractical to mark the site, an orange armband may be placed on the correct side in a location visible after prepping and draping, or for patients who refuse site marking. A significant change is that the exception for marking “obvious laterality” has been removed. Physicians noted that exception created risk for the patient in that patients often had more than one “obvious” condition, wound, or injury, and that what may have been obvious to one professional may not be to another. For this reason, site marking is required, even if the laterality or level seems obvious from presentation. This consistency will also help team members be certain of when to speak up to ensure patient safety.
Please review the policy (policy page, under General Clinical House Wide, Universal Protocol) and contact Dr. Matt Boles or Deni Hoover with any questions. Most importantly, thank you for your ongoing dedication to preventing patient harm through procedure verification, site marking and time out.