Universal Universal ProtocolProtocol

At completion of this session each individual will be able to:1.Verbalize the process to ensure the correct identification of the right patient, right procedure, and correct site using two patient identifiers.2.Verbalize the alternate site marking process.3.Verbalize the individual responsible for site marking on the patient.4.Verbalize the how the site is to be consistently and unambiguously marked.5.Verbalize and demonstrate use of the surgical interventional checklist and documentation of the “time out”.6.Verbalize the components of a “time out”.7.Be able to lead a “time out”.8.Verbalize when multiple “time outs” are required.9.Verbalize the site marking requirement to be able to see the initials of the physician after the draping procedure.10. Verbalize where the “time out” documentation is completed.

Learning Objectives:Learning Objectives:

Use of Two Patient Use of Two Patient IdentifiersIdentifiers

Patient’s Name Patient’s Medical Record

Number

Identification of the Correct Identification of the Correct SiteSite

Site must correlate with:

Patient’s interpretation

Medical record documentation, e.g. H&P

Consent

Physician’s order

Radiographic studies

Site MarkingSite Marking

Alternate Site MarkingAlternate Site MarkingUse for patients that do not want to be marked:

Use of neon pink armband placed on the side specific ankle or wrist

Physician writes name of procedure on armband with his initials

Must correlate with medical record documentation of correct site and patient’s understanding

““Time Out”Time Out”Team stops all activities to identify:

Correct patient

Correct site

Correct Procedure

Ensures all necessary equipment/ supplies are available

Identifies any safety concerns

Documents time out and team involved on the pre-procedural checklist