the operation must be marked prior to the patient being taken into surgery. this denotation of where the procedure is to take place, what area of the body is predetermined and marked prior to induction of anesthesia.
(Name of your facility should go here) Policy and Procedure for Operative Site/Site Marking and Verification 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. DEFINITIONS: 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 insertion. “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 proceeding. 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”. Exemptions: 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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