policy & procedure for operative site/site marking and verification by compliancedoctor


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Policy and Procedure for Operative Site/Site Marking and

POLICY: Operative and Invasive procedures are performed on the correct
patient and on the correct site/side by requiring a preoperative/pre-
procedural marking that unambiguously identifies the site of an
operative/pre-procedural location. This process will be a coordinated
effort between the attending physicians of record, nurses, and the
anesthesia care team (when applicable). All responsible personnel will
confirm the appropriate site/side and never assume another individual
has correctly performed the task. Routine “minor” procedures are not
within the scope of this policy.

Operative and Invasive Procedures: Procedures which expose patients to
more than minimal risk, including procedures done in settings other
than the operating room such as special procedure units, Endoscopy
units or the use of Fluro. Procedures that involve puncture or incision
of the skin, or insertion of an instrument, or foreign material into
the body, including but, not limited to: (a) percutaneous aspirations,
(2) biopsies, (3) vascular, and (4) endoscopies are within the scope of
this definition.

Anesthesia Procedures: Procedures performed either before a surgical
procedure (e.g. regional nerve blocks-brachial plexus) or independently
(e.g. spinal facet blocks).

Routine “Minor” Procedures: Veni-puncture, peripheral Intravenous line
placement, insertion of nasal gastric tube, or Foley catheter

“Time out”: All work should cease during a period of time when all
members of the operative/procedural team, using active communication,
confirms correct patient, correct procedure, correct site and side,
medications on the sterile field and availability of all items
anticipated for procedure to begin.

Additional Confirmatory “Time Out”: All work is to cease when a new
surgeon arrives and assumes primary responsibility for the case, or if
the patient/operative site is re-draped. The name of the patient and
the correct site and side of the procedure is to be verified before

Medication “Time Out”: before the start of the case, the
surgical/procedural team MUST verify ALL medications on the sterile
field. This will include the drug name, strength and the maximum dose
calculated for all injectables on the filed, as well as a discussion
related to any cautions or contraindications for administration. For
Pediatric patients, ALL dosages will be weight based and calculated in
mg/kg. Any medication brought to the sterile field after the start of
the case/procedure will require a subsequent “Time Out”.
Observer: A Registered Nurse can perform in the role of an “Observer”
as the second confirmatory party to “Time Out”.


   1. Single organ cases, which do not involve laterality (e.g.,
hysterectomy, appendectomy).

   2. Spinal block for pain management or epidural does not require an
intra-operative marker if fluoroscopy is used. However, it does require
skin marking.

   3. Interventional cases for which the catheter/instrument insertion
site is not predetermined.

      (4-omitted 05/13/2009 @ 0645)

   5. Endoscopic or other procedures done through a midline orifice.

   6. Situations in which the primary pathology itself is plainly
visible (single laceration).

   7. When the operative pathology has been identified by real time
imaging in the immedi
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