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Pre-operative verification process
Verification of the correct person, procedure and site should occur (as applicable):
- At the time of surgery/procedure is scheduled.
- At the time of admission or entry into the facility.
- Anytime the responsibility for care of the patient is transferred to another caregiver.
- With the patient involved, awake and aware, if possible.
- Before the patient leaves the preoperative area
of enters the procedure/surgical room.
A preoperative verification checklist may be helpful to ensure availability and review of the following, prior to the start of the procedure:
- Relevant documentation (e.g., H&P, consent).
- Relevant images, properly labeled and displayed.
- Any required implants and special equipment.
Marking the operative site
- Make the mark at or near the incision site. Do NOT mark any non-operative site(s) unless necessary for some other aspect of care.
- The mark should be unambiguous (e.g., use initials or "YES" or a line representing the proposed incision; consider that "X" may be ambiguous).
- The mark should be positioned to be visible after the patient is prepped and draped.
- The mark should be made using a marker that is sufficiently permanent to remain visible after completion of the skin prep. Adhesive site markers should not be used as the sole means of marking the site.
- The method of marking and type of mark should be consistent throughout the organization.
- At a minimum, mark all cases involving laterality, multiple structures (fingers, toes, lesions), or multiple levels (spine). Note: In addition to pre-operative skin marking of the general spinal region, special intraoperative radiographic techniques are used for marking the exact vertebral level).
- The person performing the procedure should do the site marking.
- Marking should take place with the patient involved, awake and aware, if possible.
- Final verification of the site mark should take place during the "time out."
- A defined procedure should be in place for
patients who refuse site marking
Exemptions:
- Single organ cases (e.g., Cesarean section, cardiac surgery).
- Interventional cases for which the catheter/instrument insertion site is not predetermined (e.g., cardiac catheterization).
- Teeth-BUT, indicate operative tooth name(s) on
documentation OR mark the operative tooth (teeth) on the dental
radiographs or dental diagram.
Premature infants, for whom the mark may cause a permanent tattoo.
"Time out" immediately before starting the procedure
Should be conducted just before starting the procedure, will be done, just before starting the procedure. It should involve the entire operative team, use active communication, be briefly documented, such as in a checklist (organization should determine the type and amount of documentation) and should include:
- Correct patient identity.
- Correct side and site.
- Agreement on the procedure to be done.
- Correct patient position.
- Availability of correct implants and any
special equipment or special requirements.
The organization should have processes and systems in place for reconciling differences in staff responses during the "time out."
Procedures for non-OR settings including bedside procedures.
- Site marking should be done for any procedure that involves laterality, multiple structures or levels (even if the procedure takes place outside of an OR).
- Verification, site marking, and "time out" procedures should be as consistent as possible throughout the organization, including the OR and other locations where invasive procedures are done.
- Exception: Cases in which the individual doing
the procedure is in continuous attendance with the patient from the time
of decision to do the procedure and consent from the patient through to
the conduct of the procedure may be exempted from the site marking
requirement. The requirement for a "time out" final verification still
applies.
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