Q. Must all procedures be marked? Are there any exceptions?
A. The overall purpose of the Universal Protocol is to improve patient safety by preventing procedural errors. As historically stated for the Universal Protocol, procedures that have a midline approach intended to treat a single, midline organ (for example Cesarean section or CABG) , as well as endoscopies without intended laterality, do not require site marking - they are exempt. Also, site marking is not required before procedures in which there is no predetermined site of insertion such as cardiac catheterization and other interventional procedures. All other procedures are required to be marked.
Please note, however, that for those procedures in which site marking is not required, the other requirements of the Universal Protocol still apply. Based upon these statements, and with a focus on procedure safety, each organization is expected to clearly define for itself which procedures will fall outside the requirements for site marking and all healthcare workers involved in operative and other invasive procedures should know these procedures and the processes for their management.