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SURGICAL
SERVICES
DIVISION
POLICY
Name of Policy
Universal Protocol for Preventing Wrong Patient, Wrong
Procedure, Wrong Site Surgery Operative/ Procedural
Areas
Policy Number OR PC-2
Date Effective November 18, 2002
Date Last
Reviewed
January, 2009
Responsible
Dept.
Surgical Services

PURPOSE: To prevent wrong patient, wrong procedure, wrong site surgeries in hospital and
ambulatory settings.

POLICY STATEMENTS: This policy serves to supplement UNC Health Care System Administrative
Policy Universal Protocol for Preventing Wrong Patient, Wrong Procedure, Wrong Site
Surgery which will be followed at all times.

PROCEDURES:

1) IDENTIFICATION OF PATIENTS
A) A registered nurse will identify the patient:
i) on arrival in the pre-op area, i.e.. Procedural Care Suite, Main OR Holding Area, W&C PCS, 4
th

Floor PCS, or ASC Preoperative Area
ii) on arrival in the procedure room or operating room
iii) on arrival in the post anesthesia area(s)
iv) anytime transfer of care occurs
B) Identification of a patient, per Nursing Procedure Identification, Patient, is achieved:
i) verifying first and last name
ii) verifying date of birth
iii) comparing the Medical Record number on the bracelet with the medical record/ chart
iv) verification can be provided by the patient, family member or significant other.


2) SURGICAL SITE MARKING
A). The procedure is marked by a licensed independent practitioner (a surgeon) who will be involved
directly in the procedure and will be present at the time the procedure is performed.

B) the surgical incision site(s) or area will be marked when procedures involve right/left distinction,
multiple structures/ lesions (i.e., fingers and toes or moles), and levels (as in spinal procedures).
C) both sites are marked for bilateral cases, i.e. for Total Bilateral Knee Arthroplasty, both the R and L
knee are marked
D) For procedures that involve laterality of organs, but the incision or approach maybe from midline or
natural orifice, the site is still marked and laterality noted.
See UNC Hospital Policy ADMIN0141 Universal Protocol for Preventing Wrong Patient, Wrong
Procedure, Wrong Site/Surgery for other specific exemptions.
E) If the direct surgical side/site can not be marked, an alternate marking site will be agreed upon by
the surgical team members

F) whenever possible, the patient and/or family member and/or significant other will be involved with
identifying and marking the correct surgical site/side of surgery.
G) the area or skin closest to the area will be marked with the initials of the surgeon marking on the
correct site/side.
H) the initials are made at or near the incision site with an indelible marker that is sufficiently
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permanent to remain visible after completion of the skin prep and sterile draping. The mark is
positioned to be visible after the patient has his or her skin prepped, is in his or her final position and
sterile draping is completed.
I) the surgeon will document that the Site was Marked:
(1) if Outpatient or Same Day Admission patient, this documentation is located on the Pre-
Procedure Assessment form
(2) if Inpatient, this documentation can be performed on the Record Sheetor the Pre-op
Check List both located in the chart or as an addendum or attestation in WEBCIS.
J) the site may be marked prior to the day of surgery, as long as the mark meets the specifications in B)
above
I) If the site of surgery has not been marked, the nurse will page the Chief Resident or the
Attending Surgeon.

3) PREOP VERIFICATION
A In the Preoperative Area, the nurse will verify:
(1) identity of the patient,
(2) verify that the operative site/side has been marked and documented, if applicable,
(3) confirm the consent
(4) confirm the history and physical is available in the medical record.
(5) confirm the nursing assessment
(6) confirm that the 24 hour update has been signed
(7) confirm the available of blood products, if needed
(8) confirm the location of any implanatable devices in place, if applicable

The PreOp RN will document in the electronic medical record

B. The Intraoperative Nurse will verify preoperatively the following:
(1) verify that diagnostic and radiology studes are available, if applicable
(2) verify that implants, devices and special equipment are available, if applicable
The IntraOP RN will document in the electronic medical record


4) REGIONAL ANESTHESIA VERIFICATION AND TIME OUT PreOp or Post OP, NOT in the
operating room
A)On arrival to the Holding Area or other area in which the Regional Anesthesia will be
performed, prior to sedation, the Holding Area Nurse or the Circulating Nurse will perform the
patient verification.
B) The side/ site is marked by the anesthesia care provider per UNC Hospital Policy
ADMIN0141 Universal Protocol for Preventing Wrong Patinet, Wrong procedure, Wrong Site/Surgery

C)The Anesthesia TIME OUT will be performed prior to the administration of regional
anesthesia/peripheral nerve block, by the Anesthesiologist or CRNA, and the patient, parent or
guardian (when possible). The TIME OUT will verify the consent form and orally and
simultaneously verify the correct:
a) patient name
b) planned surgical procedure site and side
c) planned anesthesia procedure

The Anesthesia verification and time out is documented on the Anesthesia Regional Block report
of in the electronic medical record.

The Anesthesia Verification and Time Out that occurs outside the operating room does not supercede the
Verification and Time Out required in the operating room.

5) SIGN IN on entry into the operating room
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A) The circulating nurse will:
i) review the surgery scheduled.
ii) identify the patient with name, DOB, and the comparison of the medical record number with
the bracelet and the medical record/ chart.
iii) review the medical record/ chart to insure informed consent, and history and physical
iv) confirm that the site/side of surgery has been marked, if applicable
v) confirm availability of diagnostic and radiology test results, if applicable
vi)confirm blood availability, if applicable
vii)confirm that implants, devices and special equipment necessary for the procedure are available,
if applicable
viii) confirm that all labeled fields on the white board have been recorded
ix) document that all patient and surgery indentifiers have been confirmed in the electronic
medical record.

6) TIME OUT Prior to Induction or Regional Block performed in the operating room
A) In the Operating/Procedure Room, before the induction, all relevant members of the surgical team
(including the Attending Surgeon(s), the anesthesia care provider, the
Circulating Nurse, and the Scrub Nurse or Technician) will orally and simultaneously verify the
correct:
i) patient identity
ii) allergies based on patient history
iii) planned procedure and correct consent
iv) side/ site marked, if applicable
v) patient position ( safety Precautions)
vi) availability/presence of implants, special equipment, or critical supplies required during the
procedure based on patient need., if applicable
vii) Relevant images labeled and displayed, if applicable
vii) preoperative antibiotics available to be given, if applicable

B) This is the TIME OUT and occurs:
i) immediately prior to induction.
ii) when two or more procedures are being performed and the MD team changes, a complete
TIME OUT is performed prior to the start of the subsequent procedure.
iii) when two or more procedures are being performed by separate teams, at the same time, each
Attending Surgeon is expected to be available at TIME OUT.

C) The Joint Commission accreditation requires that TIME OUT be performed prior to induction with
the Attending surgeon and the other relevant team members as outlined in A). Exceptions to this
protocol would be related to patient safety. Examples would be a red trauma or a patient whose
induction in the operating room must not be delayed. These exceptions are not routine. Should an
exception exist, the TIME OUT, in its entirety, must be performed as soon as possible

D) The TIME OUT is not to be combined with the SIGN IN ( entry into the operating room) or the
VERIFICATION ( confirmation prior to incision).

E) Personnel Responsibilities
i) the circulator is responsible to ensure that the TIME OUT is initiated.
ii) all relevant team members will participate in the TIME OUT.
ii) during the TIME OUT, all other activities are suspended, to the extent possible without
compromising patient safety, so that all relevant members of the team are focused on the
active confirmation of those item listed in A).
iv) the circulating nurse is responsible for documenting the TIME OUT in the electronic medical
record.

7) PreIncision VERIFICATION - Prior to Incision or Prior to Procedure Start
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A) The verification will include a licensed independent practitioner (surgeon), anesthesia care
provider, circulating nurse and scrub nurse or technician.

B) The following will be verbalized:
i) correct procedure
ii) correct side/ site
iii) correct position
iv) antibiotic started, if applicable
v) prep dried

C) The circulator will document this verification in the electronic medical record

8) SIGN OUT
A) Before the patient exits the OR room, the circulator will verify with the surgeon:
i) Procedure(s) performed
ii) specimen(s) removed and correct labeled
iii) counts status
iii) specialty Post Op Bed or location, as required.




REFERENCES: UNC Hospital Policy ADMIN0141 Universal Protocol for Preventing Wrong Patient,
Wrong procedure, Wrong Site-Surgery 2008.
UNC Hospital Nursing Procedure Identification, Patient 2008.
The JC Universal Protocol For Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery 2009.
the JC Guidelines for Implementing the Universal Protocol For Preventing Wrong Site, Wrong
Procedure, Wrong Person Surgery 2009.