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How should we perform the "time out" process in my surgery center?

Ambulatory Accreditation Report, September 15, 2006

Surgical site marking and the time out or surgical pause are two of the three requirements of the JCAHO Universal Protocol for preventing wrong site, wrong procedure, wrong person surgery. For JCAHO-accredited organizations following both the hospital and ambulatory standards, these appear as National Patient Safety goals 1B (site marking) and (time out) and in the Provision of Care chapter as PC.13.20. Whether an ambulatory facility is accredited or not, it is prudent to recognize that the Universal Protocol requirements promote safe patient care, treatment, and services.

Q: Who should implement the time out in the ambulatory OR center?
A: The Universal Protocol does not specify who should initiate the time out, but consistency promotes compliance. The organization should assign responsibility to initiate the time out to an operating team function or role, with the expectation that the person in that role will always be the one to initiate the time out.

The time out must be done immediately prior to the beginning of the procedure and have active involvement of the entire surgical team. This means there is 100% oral or visible agreement (nod or gesture) following the time out statement. At a minimum, the time out statement must include:

  • patient identity
  • correct side and site
  • procedure to be done
  • correct patient position
  • availability of correct implants or special equipment or requirements

The surgery must not proceed until there is agreement by all team members.

Q: How do you document the time out process in the chart?
A: The Universal Protocol requires that the time out be "briefly documented." Documentation can be accomplished with this action being on a checklist or a checkbox on any document that is a part of the permanent medical record. There is no requirement to document the content of the time out statement or the names of the individuals participating in the time out. It is the practice that is documented.

Q: Who should mark the operative site?
A: The Universal Protocol states that the person doing the procedure should (allowing flexibility) mark the site, but when this is not feasible, another member of the surgical team who is informed about the patient and the procedure must (required) mark the site. It is appropriate to delegate site marking to an RN surgical team member, unless prohibited by nursing state law or regulation.

Q: Where does site marking happen?
A: The site should be marked prior to moving the patient into the OR or procedure room. This will usually be in a "holding" or pre-operative area.

Site marking Do's and Don'ts

  • Use an unambiguous mark, such as "yes," surgeon's initials, or a line marking the intended incision site
  • Use a marker sufficiently permanent to not wash off during the skin prep
  • Place the mark to allow it to be visible after draping
  • Use a consistent procedure throughout the organization
  • Don't use an X to mark the side as this is ambiguous
  • Don't mark the nonsurgical site
  • Don't use adhesive skin markers for site marking

Additional FAQ and guidelines for implementing the Universal Protocol are available on the JCAHO website by clicking here.

-Answered by Linda Goodwin RNC, M.Ed, patient safety and regulatory specialist and bariatric surgery coordinator, Evergreen Hospital

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