Universal Protocol
This must be conducted immediately before the procedure starts, involving the entire surgical team.
What is a time out?
Hair should be removed using this method if necessary.
What are electric clippers?
This information must appear on all medication containers and syringes on the sterile field.
What is drug name, strength, and expiration date?
Counts are performed to prevent retention of these items.
What are sponges, sharps, and instruments?
Patients must be identified using at least this number of identifiers.
What are two patient identifiers?
This process verifies the correct patient, procedure, and surgical site before surgery.
What is the Universal Protocol?
Surgical hand antisepsis must be completed before this event.
What is donning sterile gloves and gown?
These two qualified individuals should verify medications transferred to the sterile field whenever possible.
Who are two licensed caregivers?
This count must be completed before would closure begins
What is the closing count?
This communication method is used to verify critical verbal or telephone orders.
What is Read Back?
The individual performing the procedure is responsible for completing this on the patient when applocable.
What is site marking?
This measure is used to reduce the risk of surgical infections and should be given within the appropriate timeframe before incision.
What are prophylactic antibiotics?
This high-alert medication often requires an independent double check.
What is insulin, heparin, or another high-alert medication?
If counts are incorrect, this action must occur before the patient leaves the OR.
What is reconciliation of the count and surgeon notification?
(If count is not rectified an x-ray must be done and read by a physician)
This Joint Commission goal focuses on preventing falls and patient injury.
What is reducing the risk of patient harm from falls?
These three elements must be verified before incision.
What are the correct patient, correct procedure, and correct site?
This organization publishes evidence-based guidelines for preventing surgical site infections.
What is AORN?
Unlabeled medications on the sterile field should be handled this way.
What is discarded immediately?
This diagnostic procedure may be necessary when a count discrepancy cannot be resolved.
What is an intraoperative x-ray?
(must be read by a physician)
This process helps ensure all caregivers have current information about a patient's medications.
What is Medication reconciliation?
This must occur whenever there is a change in procedure, surgeon, or patient positioning that creates uncertainty.
What is a repeat Time Out?
These sterilization monitoring tools confirm exposure to sterilizing conditions.
What are chemical indicators and biological indicators?
Joint commission requires medication labeling even when medications are not administered immediately.
What is on and off the sterile field during perioperative care?
These staff members are primarily responsible for performing surgical counts.
Who are the circulator and scrub person?
The National Patient Safety Goal requiring improvement in staff hygiene targets reduction of these infections.
What are healthcare-associated infections (HAIs)?