Correct Site Surgery - Universal Protocol 


A preprocedure verification process is conducted as described in the Universal Protocol Verification of the correct person, procedure and site. The purpose of the preprocedure verification process is to make sure that all relevant documents and related information or equipment are available prior to the start of the procedure, correctly identified, labeled and matched to the patients identifiers, reviewed and are consistent with the patients expectations and with the teams understanding of the intended patient, procedure and site. Preprocedure verification may occur multiple times at different locations by different medical staff before the procedure. However, the preprocedure time out will always be performed.


1)Time out is performed immediately before the procedure.

2)Procedure room technologist announces timeout in the presence of the endoscopist, anesthesiologist, medical assistant and any other staff involved in the care of the patient during the case. Announcement is performed before any anesthesia is administered and patient is fully conscious. During the timeout, staff members must direct their full and undivided attention to the person announcing the time out.

3)Procedure room technologist will verify the patient using multiple forms of identifiers and verify the correct procedure to be performed

4)All staff involved in the time out must agree with the time out. Once this is done, the completion of the time out will be announced and documented. 

Should there be a discrepancy on any of the above information, any necessary corrections will be made and the time out will be started again.  If after a second time out there is still a discrepancy, a decision will be made regarding cancelling the procedure.
Approved By Governing Board    
Control #375.3