Universal Protocol
When the nurse is doing the pre-procedure verification process, these items related to the procedure all need to be checked and match.
What are: The H&P (within 30 days, update is needed the day of surgery)
Consent form
The patient's answer when asked about their procedure
This is the final assessment, an immediate pause by the entire clinical team to confirm the correct patient, procedure, and site are identified and that all relevant documents, related equipment and other necessary items are available
What is the TIME OUT
This must occur when there is more than one possible location (laterality, multiple structures or levels) for the procedure and involves the surgeons initials
What is site marking
These are the times during a procedure when a surgical count must be performed
What is before, closure of hollow organ, closure of first layer, closure of skin, request of any team member and permanent relief
These are the three steps in Universal Protocol
What are:
Pre-procedure verification process
Site marking
Time-Out
True or False: If two or more procedures are being done on the same patient a time out must be completed before each if the provider performing the procedure is different
What is TRUE.
Who can do the site marking?
Site marking is done by only the surgeon/proceduralist, with the patient involved, awake, and aware if possible.
In limited circumstances site marking may be delegated to an individual who meets qualifications (resident, APRN or PA), is familiar with the patient; and will be present during the procedure
If a package of raytecs or lap sponges have an incorrect number on the initial count and the patient is not in the room, what should you do?
What if the patient is in the room?
What is
1. Remove the sponges from the field and the room then open another package
2. Remove sponges from the field, label them then bag them up in a plastic bag and keep in the room. Nothing can be removed until the patient has left and counts are correct.
This is performed at the end of the surgical procedure prior to the surgeon & patient leaving the OR suite and included confirmation of correct counts, surgical procedure, wound class & specimen identification and labeling
What is debriefing
According to Saratoga Hospital policy, at a minimum the surgical team agrees to these four areas within the time out
Patient’s identity (patient Name and DOB)
Procedure to be done including side/site
Validation if the Site is Marked and visible after draping
Assessment of flammables: ? Application site dry before draping and utilization of equipment ? No pooling of solutions or have been corrected ?
Solution-soaked materials have been removed from OR prior to draping and the use of surgical devices
These are some exemptions to the rules of site marking.
Single organ cases
life threatening emergencies
spinal blocks
Interventional procedure cases in which the catheter/instrument insertion site is not predetermined
dental cases
There is an obvious wound or lesion that is the site of the intended procedure
patient refusal- requires documentation
True or false: In order to count sponges correctly, you do not have to separate out each sponge for visualization
What is FALSE
Sponges must be separated out to ensure correct number. It is best practice to leave the paper band on until you are counting
True or False: A surgical consent is not a legal document so abbreviations are appropriate to use
What is FALSE
What do you do if a consent has abbreviations on it?
During the Time-Out, everyone present in the procedural room is doing this.
What is: PAUSE all non-critical activities to focus on active participation in the Time-Out
If the patient is refusing to have their site marked the perioperative team member needs to do this.
try to help them understand why the site needs to be marked- patient safety
document the patient is refusing traditional marking
notify surgeon and team
These are the staff members involved in properly verifying and disposing of sharps from the sterile field
Who are the circulator and the scrub tech
Saratoga Hospital aims to minimize avoidable risks during procedures by taking steps to make sure the correct patient is getting the intended procedure by implementing this policy
What is Universal Protocol
If there is movement during the time out, this is what must occur
What is restart the time out
Also, verify that everyone in the room is ready
The site marking must be:
done before the procedure begins (if not an emergency)
clear
visible after skin is prepped and draped
Loud music, emergent cases, equipment alarms, OR traffic, loud talking, stress and undocumented counted items can all contribute to this
What is an incorrect count
What is the procedure for an incorrect count?