Accreditation

Greeley Reflections

Accreditation Connection, December 29, 2010

Revisiting the Universal Protocol for simple, one-person procedures

 

Part 5 of 7

Alternate process (UP.01.02.01 EP 5)

There's been significant confusion over the years about what sort of alternate to site marking should be in place for patient refusals, neonates, teeth, cardiac catheterizations and the like. The FAQs gave examples, many of which did not work for some procedures and settings.

But since the FAQs are gone, so why not simply design a process that calls for documenting the site on a piece of paper or computer screen that is available at the location of the procedure and referring to this document in lieu of a site mark? We believe this would comply with the requirement and reflect a common (and safe) clinical practice for simple procedures. (Banding or flagging may still be appropriate for more complex surgical procedures.)

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