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

• Patients Name
• Patients Medical Record Number

4
Identification of the Correct Site

• Site must correlate with
• Patients interpretation
• Medical record documentation, e.g. HP
• Consent
• Physicians 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 patients 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