Joint Commission (JC) Guidelines

Guidelines for Implementation of the Universal Protocol for the Prevention of Wrong Site, Wrong Procedure and Wrong Person Surgery

These guidelines provide detailed implementation requirements, exemptions and adaptations for special situations.

Pre-operative verification process

  • Hospitals should identify the methodology of pre-procedure verification and site marking based on their own circumstances. Verification of the correct person, procedure and site should occur with the patient awake and aware, if possible:
  • At the time of surgery/procedure is scheduled.
  • At the time of pre-admission and testing
  • At the time of admission or entry into the facility.
  • Anytime the responsibility for care of the patient is transferred to another caregiver.
  • Before the patient leaves the preoperative area or enters the procedure/surgical room.

A standardized 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 intra-operative radiographic techniques are used for marking the exact vertebral level).
  • The marking should be made by an individual that is familiar with the patient and is involved with the patient’s procedure. This individual is encouraged to be the surgeon or (1) individuals permitted through a residency program to participate in the procedure (2) a licensed individual who performs duties in collaboration with the surgeon i.e. nurse practitioners and physician assistants.
  • 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

A time out should be conducted in the OR/procedure room before the procedure/incision. 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.

The hospital/organization may, in conjunction with the hospital staff, may create processes that are not specifically addressed in the “time out” to establish a standardized protocol for patient safety. There should be 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.