Medical Staff House Staff Orientation Manual - Montefiore Medical ...

VERIFICATION OF OPERATIVE PROCEDURE SITE AND PATIENT
IDENTIFICATION
Patient Care Manual: Code O-4
Note: This summary contains key points of this policy and the related procedures. For a
complete understanding of all the relevant provisions, it is necessary to thoroughly read the full
policy.
WHAT:
It is the responsibility of all associates involved in the care of the patient undergoing an
operative/invasive procedure to verify the correct patient, procedure and procedure site. It is the
Attending physician’s responsibility to document this verification process on the informed
consent tool on the day of the procedure. This policy ensures that the correct surgery/procedure
is performed at the correct side on the correct patient and eliminates wrong-side, wrong-site,
wrong-patient, wrong-procedure surgery.
WHO:
• This policy applies to patients undergoing operative/invasive procedures
• Attending physicians
• All associates involved in the care of the patient undergoing the procedure
WHEN:
This policy applies to all operative and other invasive procedures that expose patients to more
than minimal risk.
WHERE
This policy includes but is not limited to procedures done in settings other than the operating
room, such as in special procedure units, endoscopy units, and interventional radiology units,
procedures done at the bedside and those performed outside of the operating room (e.g.,
ambulatory sites).
HOW
• Pre-operative/procedure verification process
Prior to the start of the procedure confirm appropriate documents are available, have been
reviewed and are consistent with the staff’s understanding of the patient, procedure and site.
• Marking process
The procedure site will be marked for invasive procedures involving right/left distinction,
multiple structures, or levels. The Attending Physician, or designee will mark the site before the
patient enters the procedure room and prior to the administration of medications with sedative
effects, except in the case of minors or other patients with decision makers.
• Final Verification Process (“Time Out”)
Immediately prior to the start of any surgical/invasive procedure, a final verification “Time Out”
will be conducted to confirm the correct patient, procedure and procedure site. The process will
be initiated by the circulating nurse and take place between the circulating nurse, anesthesiologist
and surgeon. Before the incision is made, each team member will verbally confirm the name of
the patient, the planned procedure and the procedure site. If there are any discrepancies in
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