Q: What specific surgical procedures require marking of the site?
A: Site marking is required by national patient safety goal 1b and is one requirement of the Universal protocol. In addition standard PC.13.20 EP 9 requires "the site, procedure, and patient are accurately identified and clearly communicated using active communication techniques, during a final verification process such as a time-out before the start of any surgical or invasive procedure."
As noted in our FAQs on the Joint Commission website, the Universal protocol requirements are applicable to all operative and other invasive procedures that expose patients to more than minimal risk, including procedures done in settings other than the operating room such as a special procedures unit, endoscopy unit, or interventional radiology suite. Certain routine "minor" procedures such as venipuncture, peripheral IV line placement, insertion of NG tube, or Foley catheter insertion are not within the scope of the protocol. In addition, marking the site is required for procedures involving right/left distinction, multiple structures (such as fingers and toes), or levels (as in spinal procedures). Site marking is not required (nor is it prohibited) for other procedures. These may include mid-line sternotomy, Cesarean section, laparotomy and laparoscopy, cardiac catheterization and other interventional procedures for which the site of insertion is not predetermined. However, most other procedures that involve puncture or incision of the skin, or insertion of an instrument or foreign material into the body, including, but not limited to, percutaneous aspirations, biopsies, cardiac and vascular catheterizations, and endoscopies are within the scope of the Universal Protocol.
Each organization will need to utilize this website explanation and identify which procedures that are being performed at their organization would expose the patient to more than minimal risk.
Beyond the FAQ explanations the Joint Commission cannot make that decision for organizations. Surveyors will use the organization's definition in evaluating compliance with the national patient safety goal, the universal protocol and the element of performance at PC.13.20.
Additionally, recognizing that Universal Protocol requirements promote safe patient care, treatment, and services, organization are certainly free to use any of the components of the protocol for any other type of procedure it so chooses.