JCAHO Protocol: Conduct A Preprocedure Verification Process
It should be stated in our protocol what to do if a patient refuses to be marked for the procedure. a. A written form should be available for this occurrence. 4. There should be further exceptions to site marking. These exceptions will include: a. Internal organs b. Interventional cases for which the site may change. c. Teeth d. Premature infants
The third JCAHO focus area is UP.01.03.01: A time-out is performed before the procedure. The part of our protocol that relates to this standard is: Time-Out Procedures. When the graph showing hospital wide time-outs is analyzed, it is obvious that we are not attaining the one hundred percent goal. While there are some aspects of the protocol that are correct, the following changes need to be made to our protocol:
1. A time-out must be called immediately before starting the invasive procedure.
2. It is standardized by the hospital.
3. It is designated by a member of the team.
4. It involves all members of the procedure team. a. This is ALL the participants who will be participating from the beginning. 5. If two or more procedures are being performed, a time-out will happen before each one. 6. Document the completion of the