Univeral Protocol
Created to decrease the incidence or wrong site, wrong procedure, wrong patient surgery
What is the Universal Protocol?
Must be visible after prepping and draping?
What is the site marking?
Required elements of a procedural time out (minimum 3)
What are:
correct patient, correct site, correct procedure, allergies, radiographs, blood or special equipment, sterilization indicators, antibiotic time, fire risk, beta blockers, warming modalities, SCDs?
Dual identifiers for patient identification
What are name and date of birth?
Nothing
What else should be taking place during the Time Out?
Per the Joint Commission, the Universal Protocol is a ____ prior to the start of surgery or any invasive procedure?
What is a requirement?
Alternative site marking form
What to use if a patient refuses to have their surgical site marked?
(Provider must document refusal and place UH Alternative site marking form in patient chart when a refusal occurs) #90119
Personnel required to participate in the Time Out
Who is: surgeon, anesthesia, surgical techs, RN circulators, any ancillary staff in the room
A patient must be determined to have _____ in order to participate in the informed consent process.
What is capacity?
(Capacity is procedure, time, and situation specific and requires that the patient express a basic understanding of medical condition, proposed treatment/procedure, and risks/benefits of accepting/refusing treatment, state decision)
Situation where, in competent medical judgement, the proposed surgery, procedure, or medical treatment, are immediately and imminently necessary and any delay occasioned by an attempt to obtain consent would reasonably jeopardize the life, health, or limb of the person affected, or would reasonably result in disfigurement or impairment of faculties.
What is an emergency condition?
Components of the Universal Protocol.
What are:
Pre-procedure verification (sign in)
Site marking
Time-out
Debrief or sign out
Surgeon or licensed independent practitioner
Who is approved to mark the site prior to surgery?
(Site marking may be delegated to a resident, APRN, or PA familiar with the patient and who will be present for the procedure.)
Sterilization indicators confirmed and special instruments/equipment ready
What is responsibility of scrub person during time out?
(This information may also be presented by circulating RN)
H&P < 30 days
Anesthesia notes with plan of care
Signed, witnessed, dated, & legible surgical consent
What items require completion prior to transporting the patient to the operating room?
Premature infants
Tonsillectomy
Teeth
Emergencies
What are procedures that do not require site marking prior to incision?
Items confirmed in the sign out of debriefing (3 or more)
What are: surgical procedure, correct, counts, specimen label, blood loss, special equipment needs, pain management or recovery concerns, wound class)
Surgeon's or delegated providers initials?
What is the required text for a site marking?
Situation requiring a second time out be performed in the OR.
What is a dual procedure involving two separate surgeons and/or teams?
(Block prior to procedure and procedures involving repositioned during surgery)
Location where you will find the Alternative Site Marking Form and Universal Protocol/Time Out Information.
What is Policy Medical?
(direct link is in Universal Protocol and Time Out Policy)
Two Challenge Rule & CUS
What is UH method of communication when a discrepancy occurs during a Time Out?
I am Concerned!
I am Uncomfortable!
This is a Safety Issue!
(Means to respectfully challenge team members when plan is unclear before starting procedure)
Elements of sign in phase of Universal Protocol confirmed with patient (minimum 3)
What are identity (dual identifiers), surgical procedure, surgical site, consent, allergies, medications,
Procedural requiring a 2-stage marking process
What is spine surgery?
(*skin must be marked with at the level of the procedure and anterior/posterior & right/left AND
Intraoperative x-rays with immovable markers must be in room for intraoperative viewing and comfirmation)
Critical or non-routine steps, Case duration, anticipated blood loss
What is the surgeon's portion of time out?
First step of any patient interaction
What is patient identification-confirmation of patient and date of birth (or FIN) -dual identifiers: both verbally and using the patient's armband?
1928/1970/2000
Harry S. Truman approved construction of Rural Jackson County Hospital
-TMC and UMKC bought hospital, and it became Truman East
-Officially became TMC Lakewood