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Universal Protocol - Pre procedure Verification

Would it be acceptable to complete the pre-procedure verification process (see UP.01.01.01) in the operating room rather than a pre-procedure holding area?

Any examples are for illustrative purposes only

Yes, in cases where the patient is not held in a pre-procedure area for preparation, it would be acceptable to complete the verifications and checklist in the operating room. Hospitals should identify the timing and location of the preprocedure verification and site marking based on what works best for their own unique circumstances. The frequency and scope of the pre-procedure verification process will depend on the type and complexity of the procedure.

Keep in mind that the final time-out (see UP.01.03.01) must occur immediately prior to making the incision with involvement of all immediate members of the procedure team. The final time-out participants MUST include, for example, the individual performing the procedure, the anesthesia providers, the circulating nurse, the operating room technician(s), and other active participants who will be participating in the procedure from the beginning.

The Universal Protocol is based on the following principles:
  • Wrong-person, wrong-site, and wrong-procedure surgery can and must be prevented.
  • A robust approach using multiple, complementary strategies is necessary to achieve the goal of always conducting the correct procedure on the correct person, at the correct site.
  • Active involvement and use of effective methods to improve communication among all members of the procedure team are important for success. 
  • To the extent possible, the patient and, as needed, the family are involved in the process. Consistent implementation of a standardized protocol is most effective in achieving safety.

Manual: Hospital and Hospital Clinics
Chapter: National Patient Safety Goals NPSG
First published date: April 11, 2016 This Standards FAQ was first published on this date.
This page was last updated on October 25, 2021
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