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Universal Protocol - Time Out Process for Procedures

Prior to performing any procedure/incision on a patient, the pre-procedure checklist will be completed for relevant documentation (H&P, consents, nursing and anesthesia assessment), diagnostic studies, required blood products, implants, devices or special equipment. The surgeon/proceduralist will initiate the Time Out Process and the entire surgical team will physically pause to both verbally and visually acknowledge and confirm the correct patient, side/site, procedure and/or implant.

It is essential to have the attention of everyone in the room!

Site Marking
Use the following guidelines when marking: 

  • Within 2" of incision
  • Visible after draping
  • Marked by physician
  • Nonoperative side left unmarked

Universal Protocol - Time Out Process for Procedures