1. Introduction to Universal Protocol (Pre-Procedure “Time-Out”) Office of Graduate Medical Education Perelman School of Medicine University of Pennsylvania

2. Universal Protocol Based on the fact that wrong site, wrong- procedure, and wrong person surgeries and procedures CAN and SHOULD be prevented Joint Commission Requirement since 2004 Required by medical board policy at all hospitals within the University of Pennsylvania Health System

3. Universal Protocol Consists of 3 Parts 1. Pre-procedure verification process 2. Site-marking 3. A “time-out” performed immediately before the procedure.

4. Pre-Procedure Verification Process Purpose is to make sure all relevant documents and related information or equipment are: 1. Available 2. Correctly labeled and matched to patients’ identifiers 3. All documents are reviewed with patient and consistent with patient expectations and teams understanding of the procedure *If at any point during this process a discrepancy is noted, the discrepancy must be resolved before the procedure and/or before the patient receives sedation or pre- medication for the procedure.

5. Site Marking Purpose is to allow staff to identify, without ambiguity, the intended site for the procedure Site marking should occur with the patient awake, involved, and aware unless a medical emergency precludes this. Final verification occurs during the “time-out” process

6. The Site Marking has the following characteristics: Is placed at or near the incision or procedure site Site marking is made using the surgeons’ or proceduralists’ initials Is made using a marker that is sufficiently permanent to remain visible after completion of the skin prep and sterile draping.

7. Pre-Procedure “Time-Out” Purpose is to conduct a final verification that the correct patient, site, positioning, and procedures are identified and that, as applicable, all relevant documents, information, and equipment are available. Conducted immediately before starting the procedure or making the first incision

8. Pre-Procedure “Time-Out”: Communication Matters Involves interactive communication between all team members including the proceduralist, his or her assistants, and the nurse(s) present in the room. During the Time Out, other activities are suspended, to the extent possible without compromising patient safety, so that the members of the team are focused on the active confirmation of the correct patient, procedure, site, and other critical elements The Time-Out includes confirming the following elements: – Correct patient using 2 patient identifiers (name, DOB, MRN) – Correct site – Agreement on the procedure to be performed

9. Emergencies For emergent (severe life threatening) situations, when it is not possible to confirm patient identification, procedure, and site with the patient or legally authorized representative, the procedure physician and clinical procedure team shall attempt to confirm the correct patient, correct procedure, and correct site utilizing existing information.

10. Procedures specifically excluded from Universal Protocol include: Venipuncture Foley catheter insertion Nasal gastric (NG) tube insertion Nasopharyngolaryngoscopy (NPL) Closed reduction of a fracture