InterCare Community Health Network
Universal Protocol for Eliminating
Wrong Patient, Wrong Site and Wrong Procedure(s)
Manual: Patient Care & Treatment Services
CHAPTER: DELIVERY OF PATIENT CARE
SECTION: PATIENT CARE AND TREATMENT
ORIGIN DATE: 12/05
REVIEW DATE: 1/13
PURPOSE : InterCare Community Health Network, as an Organization, will fulfill the expectations set
forth in the Universal Protocol for preventing wrong site, wrong procedure, and wrong person
procedure(s).
PROCEDURE: InterCare clinicians will consistently follow the Universal Protocol utilizing the preprocedural verification process, marking the procedure site, following the time-out process and
initiating a time-out before any procedure is performed.
Pre-Procedural Verification Process:
Ensures that all of the relevant documents, related information, and any equipment are available prior
to the start of the procedure and studies are available prior to the start of the procedure.
1. Relevant documents (ie. Consent, labs…) and studies must be reviewed.
2. The documents must support the diagnosis, be consistent with the patient’s expectations, and
with the team’s understanding of the intended patient, procedure, and site.
3. Missing information or discrepancies must be addressed before starting the procedure.
Two-Patient Identifier:
Prior to providing care, treatment, or services it is essential to reliably identify the individual as the
person for whom the service or treatment is intended; in addition, to match the service or treatment to
that individual. This will be accomplished by the use of two patient identifiers.
1. Acceptable patient identifiers include:
A. Name
B. Date of Birth
C. Social Security Number
2. The use of a patient’s room number is unacceptable.
3. The following are times for verification of patient identity:
A. When the patient comes to InterCare for a visit.
B. Immediately prior to the procedure being performed.
C. Anytime the patient is transferred to another caregiver.
D. Immediately before giving a medication.
E. Immediately prior to any treatment.
F. When labeling any specimen the labeling should occur in front of the patient using the twopatient identifier.
4. In the event the person is mentally incapacitated ask the legal guardian the two patient identifier
questions.
5. For an alert minor you may ask the patient the two-patient identifier and then confirm the minor
patient’s name and the procedure to be done with the parent or legal guardian.
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InterCare Community Health Network
Universal Protocol for Eliminating
Wrong Patient, Wrong Site and Wrong Procedure(s)
Manual: Patient Care & Treatment Services
CHAPTER: DELIVERY OF PATIENT CARE
SECTION: PATIENT CARE AND TREATMENT
ORIGIN DATE: 12/05
REVIEW DATE: 1/13
Marking the Site:
1. For procedures involving right/left distinction, multiple structures (such as fingers and toes),
or multiple levels, the intended site must be marked such that the mark will be visible after
the patient has been prepped.
2. For dental extractions or endodontic care, the dentist will give the patient a hand mirror,
and have the patient watch while the dentist points to the affected tooth. The dentist will
say “This is the tooth to be worked on. Is this the tooth you thought we were going to be
working on”?
3. The procedure site is marked by a Provider who is ultimately accountable for the procedure
and will be present when the procedure is being performed.
4. The marking will be the Provider’s initials.
5. Site marking is not required when the individual doing the procedure is continuously with
the patient from the time of the decision to the procedure through the performance of the
procedure or the intended procedure is the procedure confirmed.
6. Marking the procedure site must be consistent throughout the organization.
7. In the event a patient refuses site marking when warranted a wristband will be used. The
wristband will indicate the procedure (s) being performed.
Labeling Medications, Containers, or Other Solution On and Off the Sterile Field:
1. All medications must be labeled. Note: An immediate administration of the medication is one that an
authorized staff member prepares or obtains, takes directly to a patient, and administers to that patient
without any break in the process
2. Labeling must occur immediately when any medication and/or solution is transferred from the
original packaging to another container.
3. Medication labels include the following:
o Medication name
o Strength
o Quantity
o Diluents and volume (If not apparent from the container)
o Date and time are not necessary (due to the nature of the length of our procedures)
4. Verify all medications and/or solutions verbally and visually. Verification is done by two individuals
qualified to participate in the procedure whenever the person preparing the medication and/or solution
is not the person who will be administering it.
5. Immediately discard any medication and/or solution that are not labeled.
6. Remove all labeled containers on the sterile field and discard the contents at the conclusion of the
procedure. (This does not apply to multiuse vials that are handled according to infection control
practices).
7. All medications and/or solutions both on and off the sterile field and their labels are reviewed by
entering and exiting staff responsible for the management of medications.
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InterCare Community Health Network
Universal Protocol for Eliminating
Wrong Patient, Wrong Site and Wrong Procedure(s)
Manual: Patient Care & Treatment Services
CHAPTER: DELIVERY OF PATIENT CARE
SECTION: PATIENT CARE AND TREATMENT
ORIGIN DATE: 12/05
REVIEW DATE: 1/13
Time-Out
1. A time-out is required for high risk procedures, multiple procedures on the same patient, procedures
involving right/left distinction, multiple structures (such as fingers and toes) or multiple levels.
2. The Provider responsible for doing the procedure is responsible for initiating the time-out. However, if
the Provider responsible for doing the procedure does not initiate the time-out any team member in
the room is expected to initiate the time-out.
3. Conduct a time-out immediately before starting the procedure.
4. When doing two or more procedures on the same patient a time-out must be performed immediately
before each procedure is initiated.
5. During the time-out all other activities are suspended to the extent possible so the focus is on the
active confirmation of correct patient, correct site, and correct procedure.
6. During the time-out members agree at a minimum, on the following: Correct patient identity, the
correct site, and the correct procedure to be done.
7. The procedure shall not start unless all questions and concerns are resolved.
8. Documentation time-out is completed in the Electronic Health Record.
References: http://www.joint commission.org 2013
Revision Dates: 1/13
CMO Approval:
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