Universal Protocol, surgical timeouts, and EPs for 2009

Accreditation Connection, October 16, 2008

Q. Why is The Joint Commission now saying that, beginning in 2009, surgical timeouts should ideally be done before anesthesia is given? Does this mean we don’t position the patient for a timeout anymore? We certainly wouldn’t position the patient before he or she is put to sleep.This change has me a little perplexed.

A. The issue you describe is detailed in the new prepublication UP.01.03.01, element of performance (EP) 1, for 2009. This expectation is in the body of the requirement and will be published in the Comprehensive Accreditation Manual for Hospitals (CAMH).

However, the same requirement, not published in the CAMH, has been less obviously noted in the 2007 and 2008 FAQs posted to The Joint Commission’s Web site. These FAQs state that the timeout (immediate preoperative pause) must occur at the location where the procedure will be performed. With this restriction, the timeout may precede induction of anesthesia or it may occur after the patient has been anesthetized, but just prior to the beginning of the procedure.

Access the full story in the October issue of Briefings on The Joint Commission. Access is free for BOJ subscribers; nonsubscribers can purchase a copy of the story for $10 by clicking here.




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