GULF DIAGNOSTIC CENTER HOSPITAL

NURSING POLICY

Policy No: MED-NUR-P0034/10 Issue Date : July 2012 Revision No.:Original

TITLE: VERIFICATION OF CORRECT PATIENT ,CORRECT SITE AND SIDE AND CORRECT PROCEDURE IN NON OPERATIVE ROOM SETTING
Department Section Distribution : Nursing : Nursing Care : Hospital Wide

Revision Date : Next Revision : July 2014 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 Ms. Jennelyn Paderan Acting Charge Nurse, In-patient Ward Reviewed by: Name Ms. Gela Mocanu Acting Head of Nursing Department Mr. Zuher Arawi Quality Manager Approved by: Name Dr Emad Yassin Al Rahmani Medical Director Mrs. Jamal Kaddoura Hospital Director and Co-Founder

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DOCUMENT AMENDMENT RECORD SHEET

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Appendix: Yes [ ]

No [ ]

GULF DIAGNOSTIC CENTER HOSPITAL

NURSING POLICY

Policy No: MED-NUR-P0034/10 Issue Date : July 2012 Revision No.:Original

TITLE: VERIFICATION OF CORRECT PATIENT ,CORRECT SITE AND SIDE AND CORRECT PROCEDURE IN NON OPERATIVE ROOM SETTING
Department Section Distribution Date : Nursing : Nursing Care : Hospital Wide Description of Change

Revision Date : Next Revision : July 2014 Page 2 of 4 Page Effected Revision Number

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Appendix: Yes [ ]

No [ ]

GULF DIAGNOSTIC CENTER HOSPITAL

NURSING POLICY

Policy No: MED-NUR-P0034/10 Issue Date : July 2012 Revision No.:Original

TITLE: VERIFICATION OF CORRECT PATIENT ,CORRECT SITE AND SIDE AND CORRECT PROCEDURE IN NON OPERATIVE ROOM SETTING
Department Section Distribution : Nursing : Nursing Care : Hospital Wide

Revision Date : Next Revision : July 2014 Page 3 of 4

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 outside the 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 for not 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 performed immediately 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 the procedure. 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 such situations, 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 to perform 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. the procedure is not started until any questions or concerns are resolved.

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Appendix: Yes [ ]

No [ ]

GULF DIAGNOSTIC CENTER HOSPITAL

NURSING POLICY

Policy No: MED-NUR-P0034/10 Issue Date : July 2012 Revision No.:Original

TITLE: VERIFICATION OF CORRECT PATIENT ,CORRECT SITE AND SIDE AND CORRECT PROCEDURE IN NON OPERATIVE ROOM SETTING
Department Section Distribution : Nursing : Nursing Care : Hospital Wide

Revision Date : Next Revision : July 2014 Page 4 of 4

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 site 3.1.5. 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 identifiers 4.2. 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 side 4.4. Ensure the availability of correct equipment/special equipment. Complete the procedure and document the data on the Time Out verification checklist. All names to be documented 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-ED52-4C04AF8CFEBA74A732EA

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Appendix: Yes [ ]

No [ ]