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Universal Protocol - Pre procedure Verification Checklist

Please explain what is meant by the requirement to 'match the items that are to be available in the procedure area to the patient' found at UP.01.01.01 EP 3.

Any examples are for illustrative purposes only
UP.01.01.01 EP3 is a step in the pre-procedural verification process in which (prior to the start of the procedure) information and items such as implants, blood products, x-rays and/or medical devices that "are" or "maybe" required for the procedure are present and verified to ensure they are the correct items for the procedure.  

 EP 1 requires that a pre-procedure process is defined by the organization to verify the correct procedure, for the correct patient, at the correct site.  It is up to the organization to determine when this information is collected, such as at the time of scheduling or pre-admission testing, and by which team member.  Whenever possible, consideration should be given to involving the patient in this process.

EP 2 requires a standardized pre-procedure verification list of items that, at a minimum, are - or may be required - at the time of the operative or invasive procedure.  Activities to address such items may start days – or perhaps weeks – prior to the actual procedure.  Such activities may include ordering medical devices, implants or special equipment, ordering blood products, and/or obtaining copies of reports or radiographic images to ensure their availability at the time of the procedure.  Working from a standardized verification list reduces variability and thus the potential for error.  The location of the standardized list is determined by the organization. For example, in a policy/procedure, a pre-procedure checklist that may become part of the patient medical record, etc.

EP 3 is the process of comparing information about the patient and procedure with the items identified in EP 2 that are required to proceed with the procedure. The final verification process generally occurs before the patient leaves the pre-procedure area or enters the procedure room.  Missing information, supplies or discrepancies are addressed before starting the procedure.
Additional Resources:
The Joint Commission Tools and Resources: Universal Protocol
Manual: Hospital and Hospital Clinics
Chapter: National Patient Safety Goals NPSG
First published date: August 27, 2017 This Standards FAQ was first published on this date.
This page was last updated on October 21, 2021

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