Greeley Reflections

Accreditation Connection, November 2, 2009

Taking a quick look at the NPSG updates

Part 3 of 4

The Universal Protocol now applies to ALL invasive procedures rather than those that put the patient at more than minimal risk. On its face, this appears to cover many procedures not currently subject to the time out. However, we also understand that the Joint Commission intends to ease back on the scope of the Universal Protocol.

The Universal Protocol now requires that items in the procedure room be “matched to the patient.” We believe that traditional room setup practices will meet this requirement, but the language is a little confusing.

For some reason the requirement for active communication during the time out was removed from UP.01.03.01. We don’t believe this was intentional.

It is now clear that a second time out is only required when the person doing the procedure changes (UP.01.03.01). However, we’re still a little confused about the requirement for a time out before anesthesia. For example, must we document the time out twice if it is done in two phases: once before induction/intubation and again immediately before the procedure?

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