Add missing section to paper based on comments (add 2 paragraphs)

Site Identification and Verification (Universal Protocol)

Policy

Wrong-site, wrong-procedure, and wrong-person surgery can be prevented. This universal protocol is intended to achieve that goal. It is based on the consensus of experts from the relevant clinical specialties and professional disciplines and endorsed by hospital administration.

In developing this protocol, consensus was reached on the following principles:

Wrong-site, wrong-procedure, wrong-person surgery can and must be prevented.

A robust approach—using multiple, complementary strategies—is necessary to achieve the goal of eliminating wrong-site, wrong -procedure, wrong-person surgery.

Active involvement and effective communication among all members of the patient care team is important for success.

To the extent possible, the patient (or legally designated representative) should be involved in the process.

Consistent implementation of a standardized approach using a universal, consensus-based protocol will be most effective.

The protocol should be flexible enough to allow for implementation with appropriate adaptation when required to meet specific patient needs.

A requirement for site marking should focus on cases involving right/left distinction, multiple structures (fingers, toes), or levels (spine).

The policy/procedure should be applicable or adaptable to all operative and other invasive procedures that expose patients to harm, including procedures done in settings other than the operating room.

Preoperative/Preprocedure Verification Process

Verification of the correct person, procedure, and site will occur (as applicable):

1. At the time of admission/entry to the facility 2. Anytime the responsibility for care of the patient is transferred to another caregiver 3. With the patient awake and aware, if possible 4. Before the patient leaves the preoperative/preprocedural area 5. Immediately prior to beginning the operative/invasive procedure

Marking the Operative/Invasive Site:

1. All patients undergoing operative or invasive procedures will identify and mark the operative/invasive site prior to the procedure when applicable. 2. Site marking should be done for any procedure that involves laterality, multiple structures, or levels. 3. The mark should be made with a permanent marker that will remain visible after skin prep. 4. X-ray may be used as reference for identifying levels of the spine. 5. Needle localization may be used as reference for identifying breast lesions. 6. In the event any patient refuses to mark the operative/invasive procedure site, the physician will be notified. 7. Sites/procedures exempt from marking include the following:

Page 2

Endoscopic procedures

Nasal procedures

Rectal procedures

Cystoscopies

Perineal surgery

T&A's and M&T's

Single organ cases (e.g., cesarean section, cardiac surgery)

Abdominal surgery when site is not specified

Interventional sites where insertion site is not determined (e.g., cardiac catheterization, catheter placement)

8. Justification for not marking the site must be documented in the preoperation checklist. 9. If the patient/guardian is unable to mark the site or if there is any confusion concerning the appropriate site/sites, the physician will be notified to identify and mark the site. 10. Patients undergoing procedures that will require sedation or anesthesia will not be transported to the operative suite/procedural room until the site is marked as indicated. 11. Straight local procedures, using no sedation/anesthesia may be taken to OR/Minor Room and marked by the physician. 12. Laterality will be marked by writing RT for right, LT for left or BIL for bilateral as appropriate. 13. Place a "" on visible or palpable lesions (e.g., lipoma, mass, mole) Exception: Breast lesions/masses will be identified by the surgeon. 14. Spines will be marked by writing "C" (cervical), "T" (thoracic), "L" (lumbar), "S" (sacral) in the area of the back representing location and on the side of the spine the patient identifies as having greater pain. Radiographic films may be used intra-operatively to identify precise levels. 15. Teeth do not require marking, however, dental radiographs or diagrams must be marked and available at the time of the procedure.

Patient, Procedure, and Site Verification

Preprocedurally or preoperatively, the nurse providing care to the patient will complete the following:

1. Verify the operative/invasive procedure and site with the patient/guardian 2. Verify the order for the informed consent with the actual informed consent document. If discrepancy exists, notify the physician. 3. If no discrepancies exist between the informed consent and the physician's order indicating the procedure to be performed, provide the patient/guardian with a permanent black marker and instruct him or her in the following:

When side (right, left, bilateral) is indicated, mark RT (right), LT (left) or BIL (bilateral) to indicate the correct side on which the procedure is being performed.

When a mass or lesion is being removed, place a check mark (  ) on the mass/lesion to identify the appropriate site(s). Exception: Breast lesions/masses will be identified by the surgeon

Care should be taken not to obscure visualization of the lesion.

Markings should be visible once the patient is prepped and draped.

Time-Out Procedure

Immediately prior to beginning the procedure, the nurse or technologist is responsible for calling the time-out. All members of the team have the responsibility to ensure a time-out is called prior to beginning the procedure. The duration and participants of the time-out are documented in the record.

1. The patient’s chart will be used as a reference when calling the time-out. 2. At this time, all personnel involved in the procedure audibly and verbally agree on the following:

Correct patient identity

Page 3

Correct side and site

Correct procedure to be done

Correct patient position

Availability of correct implants and any special equipment

Any and all members of the team may request clarification of the correct side or site at any time.

3. In the case of any discrepancies between the consent, medical records, x-rays, imaging studies, pathology reports or any discrepancies between the patient, the patient's representative, or members of the team, all activities will be halted immediately until verifications can be completed. 4. Patients who are awake during the time-out process should be active participants.

Bedside Procedures

The above policy and procedure must be followed for any procedure that involves laterality, multiple structures, or levels. The site marking is not required if the individual performing the procedure is in continuous attendance with the patient from the time of decision and consent from the patient through to the beginning of the procedure.

Approved by Surgery Leadership Committee