PPG-GDCH-NUR-34-VERIFICATION OF CORRECT PATIENT, CORRECT SITE AND SIDE AND CORRECT PROCEDURE IN NON...

7/27/2019 PPG-GDCH-NUR-34-VERIFICATION OF CORRECT PATIENT, CORRECT SITE AND SIDE AND CORRECT PROCEDURE IN

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GULFDIAGNOSTICCENTER

HOSPITAL

NURSING POLICY Policy No:MED-NUR-P0034/10

TITLE: VERIFICATION OF CORRECT

PATIENT ,CORRECT SITE AND SIDE ANDCORRECT PROCEDURE IN NON OPERATIVE

ROOM SETTING

Issue Date : July 2012

Revision No.:Original

Department : Nursing Revision Date :

Section : Nursing Care Next Revision : July 2014

Distribution : Hospital Wide Page 1 of 4

VERIFICATION OF CORRECT PATIENT, CORRECT SITE AND SIDE

AND CORRECT PROCEDURE IN NON OPERATIVE ROOM SETTING

APPROVAL SHEET

Prepared by:

Name Signature Date

Ms. Jennelyn Paderan

Acting Charge Nurse, In-patient Ward

Reviewed by:

Name Signature Date

Ms. Gela MocanuActing Head of Nursing Department

Mr. Zuher Arawi

Quality Manager

Approved by:

Name Signature Date

Dr Emad Yassin Al Rahmani

Medical Director

Mrs. Jamal Kaddoura

Hospital Director and Co-Founder

DOCUMENT AMENDMENT RECORD SHEET

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Appendix: Yes [ ] No [ ]


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Date Description of Change Page EffectedRevision

Number

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1. PURPOSE

1.1. To provide guidelines to all members of the surgical team to be actively engaged in the

identification of the correct patient, the correct procedure and the correct site.

1.2. To conduct a final verification to promote patient safety by confirming that the correct

patient is receiving the correct procedure at the correct site and side.

2. POLICY STATEMENT

2.1. This policy shall be applicable to all clinical units and other areas in the hospital outsidethe operative theatres where investigational and/ or therapeutic procedures are

performed. This includes but not limited to Emergency Department, Non invasive cardio

clinic, Dental Clinic, Dermatology Clinic ,Radiology, Orthopedy and Endoscopy Unit.2.2. It is suggested that the Time Out process carried out for invasive procedures that require

an informed consent.

2.3. The Time-Out should be performed unless the risk outweighs the benefit. The reason fornot doing the verification must still be documented and signed.

2.4. Time-Out must be conducted in the location where the procedure is to be performedimmediately before the start of the procedure (after the patient is draped and before the

first instrument is passed).2.5. Time out process should be documented in the Site-Marking & Time out Form for

procedures performed in non-operative setting

2.6. The Time Out Form can be completed by any member of the team involved in theprocedure.

2.7. In case a discrepancy is observed during the Time Out process, the procedure should be

stopped immediately and appropriate corrective measures should be taken. In suchsituations, a Time Out must be performed again to ensure all components are checked.

2.8. The proposed procedure may be cancelled / postponed if the discrepancy has serious

impact on patients safety. This decision shall be taken by the person scheduled toperform the procedure, in consultation with the team members.

2.9. Duly completed Site marking and Time Out Form must be placed in the patients

medical record.

3. DEFINITIONS

3.1. Time-out process: refers to a process that involves active communication among the

members of the procedural team, conducted in a consistent fail safe mode.i.e. theprocedure is not started until any questions or concerns are resolved.

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The "time out" must include the following :3.1.1. Patients name and health card number

3.1.2. Consent available

3.1.3. Intended procedure

3.1.4. Correct side and site3.1.5. Correct patient position

3.1.6. Correct radiograph data/digital view imaging if applicable and availability of

implants, special equipment/requirements

4. PROCEDURE AND RESPONSIBILITY

4.1. Identify patient using 2 identifiers4.2. Ensure consent form had been signed

4.3. Confirm that the procedure and the marked site (if applicable) is the same as the

procedure ordered. Confirm the correct site and side4.4.Ensure the availability of correct equipment/special equipment.Complete the procedure

and document the data on the Time Out verification checklist. All names to bedocumented of staff that was present.

4.5. Form to be signed by the staff member completing the form with staff name and

signature and doctors stamp and signature

5. Tools/Attachments Forms

5.1. Non Operative Setting Site Verification/ Marking and Time Out Documentation Form

6. References

6.1. International Patient Safety Goals (ISPG) 2008, Joint Commission Resources (JCR) and

Joint Commission International (JCI).

6.2. Implementation Expectations for the Universal Protocol for Preventing Wrong Site,Wrong Procedure and Wrong Person Surgery

6.3. http://www.jointcommission.org/NR/rdonlyres/DEC4A816-ED52-4C04-

AF8CFEBA74A732EA

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PPG-GDCH-NUR-34-VERIFICATION OF CORRECT PATIENT, CORRECT SITE AND SIDE AND CORRECT PROCEDURE IN NON...

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