Universal Protocol

1. Universal Protocol Patient Identification Pre-procedural Checklist Correct Site and Site Marking “Time Out”

2. Learning Objectives: • At completion of this session each individual will be able to: • Verbalize the process to ensure the correct identification of the right patient, right procedure, and correct site using two patient identifiers. • Verbalize the alternate site marking process. • Verbalize the individual responsible for site marking on the patient. • Verbalize the how the site is to be consistently and unambiguously marked. • Verbalize and demonstrate use of the surgical interventional checklist and documentation of the “time out”. • Verbalize the components of a “time out”. • Be able to lead a “time out”. • Verbalize when multiple “time outs” are required. • Verbalize the site marking requirement to be able to see the initials of the physician after the draping procedure. • Verbalize where the “time out” documentation is completed.

3. Use of Two Patient Identifiers • Identification of the correct patient prior to any procedure using: • Patient’s Name • Patient’s Medical Record Number

4. Identification of the Correct Site • Site must correlate with: • Patient’s interpretation • Medical record documentation, e.g. H&P • Consent • Physician’s order • Radiographic studies

5. Site Marking • Correct site must be marked: • By the physician or licensed practitioner privileged to perform the procedure • Use of the physicians initials as the site marking • Physicians initials must be visualized by the team during the “time out”

6. Alternate Site Marking • Use for patients that do not want to be marked: • Use of neon pink armband placed on the side specific ankle or wrist • Physician writes name of procedure on armband with his initials • Must correlate with medical record documentation of correct site and patient’s understanding

7. “Time Out” • Team stops all activities to identify: • Correct patient • Correct site • Correct Procedure • Ensures all necessary equipment/ supplies are available • Identifies any safety concerns • Documents time out and team involved on the pre-procedural checklist