UNIVERSITY HOSPITAL
Augusta, Georgia
PATIENT CARE PRACTICE STANDARDS
Division or Department: No. 6010-078
PATIENT CARE SERVICES
Subject: OPERATIVE/PROCEDURE SITE
VERIFICATION and OR and PROCEDURE
CHECKLIST
I.
Page 1 of 11
Effective 1/76
Approval _________
Revised: *6/25/2007
POLICY
A.
The patient’s procedure and operative site will always be verified. As defined below, the site will be marked /identified with, when feasible, involvement of the patient. Finally a time-out procedure will be performed immediately before starting the procedure.
1.
Marking the site is required for procedures involving right/left distinction, multiple structures (such as fingers and toes), or levels
(as in spinal procedures).
2.
Site marking is not required for single organ cases such as,
Cesarean section, cardiac surgery, cardiac catheterization; PEG; and premature infants, for whom the mark may cause permanent tattoo.
3.
Site marking is not required for the point of entry of catheters and trocars used in laparotomy and laparoscopy, cardiac catheterization, and interventional procedures for which the site of insertion is not predetermined (such as angiography of the aorta).
4.
Procedures done through or immediately adjacent to a natural body orifice (e.g., GI endoscopy, dental procedures, tonsillectomy, hemorrhoidectomy, or procedures on the genitalia) or other situations in which marking the site of entry would be impossible or technically impractical are also exempt from marking the site of entry onto the body.
However, many procedures done through an entry described by 3 or 4 above are intended to treat an organ that is "right" or "left" and therefore subject to a lateralization error. Similarly, many "open" or endoscopic procedures are done through a mid-line incision or insertion site but are intended to treat an organ that is "right" or
"left." Based on the above and the requirement for marking all cases involving lateralization, mark side on which the procedure is to be preformed to indicate the correct side, even when the proposed incision/insertion site is in the mid-line.
*For additional revision dates, see end of PCPS.

Patient Care Practice Standard #6010-078
Operative/Procedure Site Verification and OR and Procedure Checklist Page 2 of 11
The mark must be positioned to be visible after the patient is prepped and draped unless it is technically or anatomically impossible or impractical to do so. In such technically difficult cases (e.g. procedures involving cranial laterality and performed through a natural orifice), an armband is to be applied to the patient. The licensed independent practitioner responsible for performing the procedure will write the name of the procedure and side (right, left, or bilateral) on the patient label of the armband.
When possible the armband will be placed on the same side as the side of the surgery.
5.
Special consideration will be given to the delicacy of the premature infant’s skin, as marking the premature infant’s skin may lead to tattooing. Neonates in SCN will be marked using the arm band system described in number 4. above. The licensed independent practitioner responsible for performing the procedure will write the name of the procedure and when appropriate the side (left, right, or bilateral) on the label of the armband.
B.
Dental procedures will be considered exempt from the site-marking requirement. In lieu of directly marking the teeth, the following procedure will be followed:
1.
Review the dental record including the medical history, as appropriate laboratory findings, appropriate charts and dental radiographs. Indicate the tooth number(s) or mark the tooth site or surgical site on the diagram or radiograph to be included as part of the patient record.
EXCEPTION: Full mouth extraction (removal of all teeth) does not require marking the diagram or radiograph.
2.
Ensure that radiographs are properly oriented and visually confirm that the correct teeth or tissues have been charted.
3.
Conduct a time-out to verify patient, tooth and procedure with assistant present at the time of the extraction.
C.
Some "bedside" procedures carry significant risk with respect to the consequences of a "wrong site" or "wrong patient" procedure. For cases that would otherwise require site marking (see I.A. above), if the practitioner performing the procedure remains with the patient continuously from the time the decision is made to do the procedure (and consent is obtained from the patient) up to the time of the procedure itself, then site marking is not required. However, if the person performing the procedure leaves the presence of the patient for any amount of time during that interval, then the site must be marked (before performing the procedure).

Patient Care Practice Standard #6010-078
Operative/Procedure Site Verification and OR and Procedure Checklist Page 3 of 11
D.
For procedures performed under emergency or urgent conditions, in most instances the practitioner performing the procedure will be in continuous attendance of the patient from the point of decision to do the procedure. If the practitioner performing the procedure has remained in continuous attendance of the patient requiring an emergency or urgent procedure, marking the site is not necessary, although the time-out to verify the correct patient, procedure, and site is still required. EXCEPTION: the emergency is such that even the time out would add more risk than benefit, for example: C-Section for fetal distress, other conditions in which the patient is in critical condition such as rupturing aortic aneurysm or profuse hemorrhage.
E.
If the patient is incompetent, cognitively impaired, or is a minor, the legal representative when available, will verify procedure/site. When site marking is required, the person performing the procedure will indelibly mark the correct site with an “O” prior to the preparation for the surgery or the procedure. The marking of the site and verification will be documented in the patient medical record. The patient always has the right to refuse to allow the site to be marked. When the patient refuses, provide the patient with information to understand why site marking is appropriate and desirable and the implications of refusing the site marking. This allows the patient to make an informed decision. Patient refusal to allow site marking will be documented in the medical record. The Protocol does not require that the procedure be cancelled because the patient refuses site marking.
Verbal procedure and site verification and the time out processes will be followed.
F.
A checklist is to be completed on patients who are having (e.g.
OR/Procedure Checklist, Admission History/Screening, Moderate
Sedation/Procedure Flowsheet):

 surgical or invasive procedures procedures that involve moderate sedation
 procedures that require the administration of medications that place the patient at risk such as Dobutamine stress tests





Areas in which these procedures might be done include:
 Main Operating Room (OR), Day Surgery and LDOR
Cardiac Cath Lab
Endoscopy
Radiology Special Procedures and procedures like biopsies and drainage performed under ultrasound
CVPL for procedures requiring moderate sedation
CVPR.

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Operative/Procedure Site Verification and OR and Procedure Checklist Page 4 of 11
G.
Imaging studies will be made available when the surgeon/procedurist needs them to perform the procedure.
H.
Site/side marking (including site armband used for marking) is to be removed by the nurse as soon as practical after procedure is complete (e.g. after dressing removed if dressing covers marking or pain subsides).
II. PROCEDURE
Site marking and time out procedures will be documented in the medical record electronically or using the appropriate form. Any discrepancies will be resolved using the process outlined in Attachment and the procedure will be stopped until all discrepancies are completely resolved. Discrepancies as well as the resolution of any discrepancies will be documented in the medical record.
A.
Site Marking:
1.
The nurse responsible for the procedure/operation preparation will verify: a.
patient consent form--EXCEPTION: those procedures which only require consent for treatment and do not require a procedure consent b.
H & P, consult note or progress note documenting the planned procedure NOTE: dictated and transcribed H&P c.
may be accessed through the electronic medical record appropriate schedule (for example, OR Schedule) identifies the proper site/procedure d.
that images required to be available by the procedurist are displayed in the requested orientation
2.
Unless an exception to site marking is applicable, the procedure/operative site/side must be marked by the licensed independent practitioner (LIP) primarily responsible (not the assistant) for performing the procedure (not an assistant).
HE/SHE will ensure proper marking as described herein and the marking will be documented in the medical record. The procedure will not begin without the site being appropriately marked, documented and visible after positioning, prepping and
draping.. When applicable, the correct procedure/surgical site will be marked with an “ O” on the body by the licensed independent practitioner primarily responsible for performing the procedure.
The patient (when capable) or the appropriate surrogate decisionmaker is to be involved in the marking process.
3.
EXCEPTION: Consent and H&P may be completed PRIOR TO
THE PROCEDURE in the procedure/operative room.
B.
Time-Out is performed immediately prior (after positioning, prepping and draping) to commencement of the procedure. If there will be more

Patient Care Practice Standard #6010-078
Operative/Procedure Site Verification and OR and Procedure Checklist Page 5 of 11 than one procedure performed during the same operative episode and more than one licensed independent practitioner is involved, and both
LIPs are NOT in the room at the original time-out, then a second time out is to be conducted when the next LIP comes into the room and prior to beginning the second procedure. The licensed independent practitioner primarily responsible for performing the procedure (not an assistant) is responsible to lead the entire team in performing the “Time
Out” process that
verifies the correct site/procedure and side (when applicable) with the patient (when possible), the entire OR or procedure team (nurse and any other assistants) caring for the patient, and the anesthesiologist/CRNA when involved in the case. The following will be the minimum information reviewed and actively verified (verbal agreement) by all members of the team during the time out procedure:
1.
Correct patient identity
2.
Correct procedure
3.
Correct site or side when laterality, multiple structures, or multiple levels are involved
4.
Correct position
5.
Availability of correct implants and any special equipment or special requirements
6.
When the surgeon/procedurist needs images to verify the site, the images are available and displayed according to the requested orientation.
When there are discrepancies in any of the above, the procedure will not proceed until all discrepancies are reconciled. See Attachment for discrepancy process.
C.
Responsible personnel will document the sections of the appropriate manual or computerized checklist or procedure form.
1.
It is permissible to sign and draw a line down contiguous rows of the paper version. The staff member should sign the last row so that their signatures are connected to indicate their responsibility for the entire section.
2.
The nurse releasing the patient to the OR or procedure area signs off the checklist or prints the computerized form after ensuring that all appropriate areas have been completed. The checklist is then placed in the patient’s medical record.
D.
The Operating Room or procedure area will call to ascertain the readiness of the patient. All pre-operative preparations are to be completed when the OR or procedure area is told the patient is ready.
E.
Completion of the OR/Procedure Checklist (manual or computer version).
Enter information on the form as described below. Instructions related to

Patient Care Practice Standard #6010-078
Operative/Procedure Site Verification and OR and Procedure Checklist Page 6 of 11 patient education and order clarification are also included in this section.
1.
NPO: The pre-operative patient is NPO after midnight unless ordered otherwise. a.
Explain to patient what NPO means. b.
Empty the water pitcher at 2400 and place NPO signs over bed and on the door. c.
Document time of last p.o. intake
2.
Insulin etc: When the patient is NPO, check with physician about administering insulin, hypertension, and cardiac drugs prior to surgery or procedure.
3.
Allergies: List all allergies on OR and Procedure Checklist including food, drugs, skin preps, latex.
4.
Patient Height and Weight: enter the patient’s height and most recent weight.
5.
Patient Labels: Ensure that the chart is labeled with the patient’s allergies and pink name label (CODE STATUS IS PLACED ON
HOLD DURING SURGERY—see G-18 Do Not Resuscitate
Orders) as appropriate. Also be sure that patient labels are available in the chart.
6.
Consent: It is the responsibility of the surgeon/physician to inform the patient of the risks, consequences, and alternatives of surgery/procedure and to secure the necessary permit from the patient. Refer to University Hospital Policy G-109, Consent. a.
Hospital employees may witness the signature only. b.
Consent is good for 30 days. c.
Telephone consent shall be permissible when a delay in obtaining consent on behalf of an incompetent individual or a minor would result in harm to the individual, or when it is impractical to obtain a written consent to convey the information necessary to make an informed consent in person. i In such a case, the physician who is to perform the procedure or to provide the treatment shall, in the presence of at least one (1) witness who is on the telephone line with the physician, convey the ii information.
If telephone consent is given, the physician giving the information must document in the medical record what was told to the patient's legal representative and must date/time and sign such notation. iii The witness shall sign the note as well, certifying that he or she heard the information being transmitted by the physician and also heard the patient's legal representative give consent.

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Operative/Procedure Site Verification and OR and Procedure Checklist Page 7 of 11 d.
Sterilization—see PCPS #6010-077 Sterilization, Elective for appropriate consent form.
7.
Site/Procedure Verification: a.
Write in the name of the procedure the patient is having, checking the appropriate box for right, left, or NA if no side is involved. b.
Ask the patient or patient’s surrogate to name the procedure he or she is having, confirming that the patient’s verbalization matches the consent form. Document c.
confirmation or reason for absence of confirmation.
Check the “yes” box if you visualize the marked procedure site. Enter the exception to site marking if the site is not marked. d.
Patients do not mark their own site at University Hospital.
8.
Lab Tests: Check lab reports on all surgical patients before surgery. The computerized document will include lab results .
Mark the paper checklist indicating which tests have been ordered and done. All test results ordered prior to a procedure should be available on the chart. If they are not, enter the reason under comments. The OR, procedure area and surgeon/physician should be notified of any abnormal values on the OR and Procedure
Checklist. Document the notification under comments.
9.
EKG, X-Ray: If pre-operative/procedure EKG and/or chest X-ray are ordered, make sure the results of the chest X-ray are on the chart prior to transporting the patient. The interpreted EKG, if ordered, should be present on the chart.
10.
History & Physical: A history and physical must be on the chart for all surgeries and procedures involving anesthesia or moderate sedation, except for emergencies. Only the surgeon/procedurist may declare the case an emergency. Notify the surgeon/physician if it is not present, and document under comments. If history and physical has been dictated, call Medical Records for STAT copy.
11.
ID Band: Check the patient’s ID band, making sure the name, doctor, and hospital medical record numbers match the same information in the medical record. Circle the location of the patient’s ID band (e.g. right arm, left leg). Patients who have arranged for autologous or designated blood should have a BLUE
ID Band. Check the box located in the Comments column on the paper column. Document as prompted on the computer version.
12.
Blood/Blood Band a.
If the physician has ordered a type and crossmatch or type and hold for blood products, make sure patient is wearing the blood band. b.
Circle the location of the patient’s blood band (e.g. right arm, left leg).

Patient Care Practice Standard #6010-078
Operative/Procedure Site Verification and OR and Procedure Checklist Page 8 of 11 c.
Call the blood bank to check if blood is ready. Note: the computer version will provide this information.
13.
Pre-op Skin Prep/Clip/Antimicrobial bath etc.: Preoperative/procedure clipping will be done as ordered by the physician. Specify the site and type of prep on the checklist. a.
Hair should be clipped as close to the time of the procedure as possible. b.
Save the scalp hair; in case of death in the OR, the hair will c.
be given to a family member or the funeral home.
Refer to Perry and Potter (2006) (6 th
Ed.), Preoperative and
Postoperative Care p. 1180 for skin preparation.
EXCEPTION: patients are not shaved; depilatory agents are only used by physician order.
Nails: Nail polish/ artificial nails will be removed from one finger on each hand and from one toe each foot so that SpO
2
may be measured and nailbeds assessed.
14.
Contact Lens etc: All contact lens, prosthesis, jewelry, hairpins, make-up must be removed before going to the OR.
NOTE: Wedding bands are to be removed. If a patient refuses to remove the wedding band, notify the anesthesiologist for further instructions. Document all actions on the checklist. a.
Check with the physician or procedure staff for nonsurgical patients. This is for the patient’s safety during surgery since some of these items could be dislodged during the procedure. b.
If the patient has applied mascara, eye ointment administered in the OR will dissolve the makeup into the eyes. This could cause corneal abrasions. c.
Remove and label any prosthesis, glasses, or contact lenses and place in a safe area of the patient’s room or give to a family member for safekeeping. Document where or to whom the item was placed or given. d.
Consult the physician and OR about patient hearing aids. If the patient is required to follow instructions during the procedure, the hearing aid may need to be left in place.
16.
Dentures: Remove dentures before sending to the OR. Check with the physician or procedure staff for non-surgical patients.
If the patient requests, they may keep their dentures in their mouth. Send a labeled denture cup to the OR with the patient. OR personnel will remove the dentures in the holding room and place them in the denture cup.
17.
Personal Clothing: Remove all personal clothing. Check with the physician or procedure staff for non-surgical patients.
Patient should wear a hospital gown to the OR. If physician has said that

Patient Care Practice Standard #6010-078
Operative/Procedure Site Verification and OR and Procedure Checklist Page 9 of 11 patient may wear underclothing document what underclothing the patient is wearing.
18.
Voided/Time: The patient should be encouraged to void before receiving pre-op medication and/or before transport. Document time of voiding on the OR and Procedure Checklist.
Check the box provided for patient with indwelling catheter. Make a notation under comments for an anuric patient
19.
Pre-Operative/Procedure Medication is administered when the OR or procedure staff notifies area they are ready for patient, or at the time the physician specifies. NOTE: medication may include antibiotics, IV fluids or medications other than sedation.
a.
Do not give pre-operative sedation if the consent form is not completed and signed, and/or the site marking has not taken place (when applicable). b.
Ask physician ordering the pre-operative medication about holding other medications. Some medications are allowed with a sip of water.
20.
Patient Safety: The patient becomes a high-risk fall (HRF) after they have been provided their pre-operative/procedure medication.
Document that HRF protocol (see PCPS #6010-082) is followed on the OR and Procedure Checklist.
21.
Medications: a.
All medications are automatically discontinued on patients going to surgery . They are only resumed post-op if ordered by the physician. b.
The current Medication Administration Record (MAR) is sent with the patient as the top sheet on the chart. Print the current MAR from the electronic medical record and include in the patient’s chart anytime the OR and Procedure c.
Checklist is completed. For patients going to surgery, print the medication reconciliation form.
Record any pre-operative/procedure medications administered on the MAR or in notes. Indicate on the OR and Procedure Checklist that the pre-op medication was administered.
NOTE: When the pre-operative/procedure medication includes narcotics or sedation, if thirty minutes or more lapses between the administration of the sedation or narcotic and patient transport, blood pressure, pulse, and respirations must be monitored every 30 minutes if the patient is at sedation level 3 or 4. If the patient is unstable, vital signs must be continued every hour until the effects of the drugs have worn off or until four hours have elapsed since the time of administration.

Patient Care Practice Standard #6010-078
Operative/Procedure Site Verification and OR and Procedure Checklist Page 10 of 11
22.
Current/Old/Divided Chart: The current and divided chart must accompany the patient to surgery or procedures. Obtain old chart to accompany patient to surgery or procedure for admissions before August 16, 2004. After this date, all closed medical records are maintained electronically (HPF). All paper records of admission are to be ordered to the unit from Health Information
Services on all surgery patients.
23.
Vital Signs: take and document vital signs prior to (but no more than two hours before) releasing patient to OR or procedure, including pulse oximetry if in use.
F.
When transferring care of the patient, it is the unit staff’s responsibility to identify the patient by comparing the identification band on the patient’s arm with the chart or slip which OR or transporting personnel will bring.
Also check the patient’s blood band, if blood is ordered.
G.
Transport to OR or Procedure:
1.
Isolation patients are treated and transported according to procedure. Personnel receiving the patient are to be notified of the type of isolation in progress (e.g. airborne isolation, etc.)
2.
Patients being transported to the intensive care units from surgery must have all of their personal belongings taken home. Admission kit with hygiene articles and special mattresses are to be transported to the intensive care unit by the sending unit.
3.
For transport of critically ill patients, see PCPS #6010-096
“Intrafacility Transport of the Critically Ill or Hemodynamically
Fragile Patient.”
4.
Notify OR or procedure area personnel who call to ascertain the patient’s readiness, if patient needs to be transported by bed, or with O
2
for respiratory support.
H.
Make the post-operative bed for post-operative patients and postprocedure patients if indicated. Check bed to make sure side rails are located on the bed and an IV pole is placed in the room.
I.
Instruct family of appropriate waiting areas.
References
JCAHO, “Universal Protocol for Preventing Wrong Site, Wrong Procedure,
Wrong Person Surgery”. Oakbrook, IL
JCAHO, “FAQ about the Universal Protocol for Preventing Wrong Site, Wrong
Procedure, Wrong Person Surgery”. Oakbrook, IL

Patient Care Practice Standard #6010-078
Operative/Procedure Site Verification and OR and Procedure Checklist Page 11 of 11
JCAHO, “Guidelines for Implementing the Universal Protocol for Preventing
Wrong Site, Wrong Procedure, Wrong Person Surgery”. Oakbrook, IL
Perry, A.G. and Potter, P.A., (2006) Clinical Nursing Skills and Techniques. (6th
Ed.).
St. Louis, MO: Mosby
Deleted: Practice Guideline #601-17, Pre-Operative Care
Policy #6020-09, 6031-09, Therapeutic Abortions and Sterilizations
Additional Revision Dates : 11/94, 11/99, 2/02, 4/02, 10/02, 1/03, 5 / 03, 10/03, 3/04, 2/05,
09/05, 6/06, 2/12/2007, 5/31/2007.

ATTACHMENT
DISCREPANCY PROCEDURE FOR SURGERY
Discrepancy Procedure
Follow the procedures below if there is a discrepancy between Consent, Schedule,
H&P, What Patient/Family Verbalized, X-rays, Labs, OR Site and/or Operative Site
Marking, or Disagreement by Team at Time-Out:
The case will be put on hold until completely resolved and all team members (including surgeon) and the patient or family (if possible) agree on the resolution.
All discrepancies and resolutions are to be documented in the patient record.
1. If discrepancy is in Operating Room Schedule: a. Notify Operating Room Team of change b. Operating Room front desk will change the Operating Room Schedule in the Surgical Information System and the manual schedule at the desk. Staff will monitor the “white board” for all add- on cases. c. Operating Room Supervisor will post corrections in receiving
Operating Room and circle with red the Operating Room case on the original schedule to alert Operating Room team of correction and cross off the incorrect procedure/site/etc. d. A copy of the corrected schedule will go to the Operating Room
Manager for appropriate action if indicated.
2. If discrepancy is in Consent:
Consents that are found to be incorrect can be modified by drawing a line through the incorrect word(s) and adding the correct word(s).
Unless the patient has been sedated, the patient must initial the correction. If the patient has been sedated, then the surrogate decisionmaker is to initial the change. If there is no surrogate decision-maker available and the patient has been sedated, then the surgery must be postponed until the patient can grant informed consent.
3. If discrepancy is in what patient/family verbalizes: a. The physician will address the discrepancy with the patient until resolved. b. The patient/family must be in full agreement regarding the procedure for the case to proceed.
4. If discrepancy in H&P: a. When applicable, the physician will be responsible for correcting the
H&P before the patient is sent to surgery.
5. If discrepancy in X-rays, Test Results, etc.: a. Notify radiology, lab or department involved to be sure that correct studies were received. b. When indicated, tests, studies will be redone to resolve discrepancy.
6. Operative Site Marking: a. Remove wrong marking b. Physician marks the site/side again with agreement from patient/family .

DISCREPANCY PROCEDURE FOR PROCEDURE AREAS
Follow the procedures below if there is a discrepancy between Consent, Schedule, H&P, What
Patient/Family Verbalized, X-rays, Labs, OR Site and/or Operative Site Marking, or
Disagreement by Team at Time-Out:
The case will be put on hold until discrepancy(ies) is completely resolved and all team members
(including physician) and the patient or family (if possible) agree on the resolution.
All discrepancies and resolutions are to be documented in the patient record.
1.
If discrepancy is in the Procedure/Radiology/Test Schedule: a.
Notify department team members involved in the case. b.
The responsible department team member will cross out the incorrect information in red on the Current Bookings Schedule and enter the correct information for use during the Time-Out procedure. c.
Notify department team members involved in the procedure of the revision. d.
A copy of the corrected schedule will go to the Department Manager for appropriate action if indicated.
2.
If discrepancy is in Consent: a.
Consents that are found to be incorrect can be modified by the physician by drawing a line through the incorrect word(s) and adding the correct word(s). b.
Unless the patient has been sedated, the patient must initial the correction. If the patient has been sedated, then the surrogate decision-maker is to initial the change. If there is no surrogate decision-maker available and the patient has been sedated, then the procedure must be postponed until the patient can grant informed consent.
3.
If discrepancy is in what patient/family verbalizes: a.
The physician will address the discrepancy with the patient until resolved. b.
The patient/family must be in full agreement regarding the procedure for the case to proceed.
4.
If discrepancy in H&P (when H&P is applicable):
The physician will be responsible for correcting the H&P before the patient has the procedure.
5.
If discrepancy in X-rays, Test Results, etc.: a.
Notify the department involved to be sure that correct studies were received. b.
When indicated, tests, studies will be redone to resolve discrepancy.
6.
Procedure Site Marking: a.
Remove wrong marking b.
Physician marks the site/side again with agreement from patient/family.