Medical Professional Publications

Time out. It’s not just for the operating room.

(From the April 2013 Issue of MedStat)

When the Joint Commission issued their standard on the Universal Protocol to prevent wrong patient, wrong procedure, wrong site surgery, they intended for the protocol to be used whenever invasive procedures are performed. The Procedure Site Verification protocol that euphemistically is known as the “time out” is well established in the operating rooms at Nationwide Children’s Hospital. However, its application outside the OR has been less consistent, in part because the policy is not clear.

A working group was formed to review and revise the Procedure Site Verification policy as it applies to invasive procedures performed outside the OR and implement an education plan for all hospital and medical staff. The working group concluded that the Universal Protocol must be used whenever an invasive procedure is performed outside the OR. They defined an “invasive procedure” as one that involves a puncture, an incision or the insertion of foreign material that exposes the patient to more than minimal risk. Those procedures require a “time out.”

Several exceptions to this policy have been established. Those include venipuncture, arterial puncture, Foley catheter insertion, dressing changes that do not require sedation, saline injections for tissue expansion and reinsertions of mature G/J tubes.

The requirement is waived if the procedure is emergent for a life threatening condition. However, at minimum, these waived procedures MUST have the following elements:

  • An order for the procedure
  • The order must be reviewed in the presence of patient/parent (electronically or on paper).
  • The two patient identifiers (name and MRN) must be used to verify the order and the patient’s identify.

When performing an invasive procedure outside the OR, an active “time out” must occur. This includes the involvement of the following personnel:

  • Licensed independent practitioner performing the procedure
  • Second licensed clinical staff member
  • Sedation provider when sedation is indicated
  • Patient and family participation when applicable

The “time out” checklist must be used and documented in the medical record or procedure note. If any team member involved in the “time out” has a concern or notes a discrepancy, a hard stop must occur and the issue resolved. Additional information about this policy is included in a revised Patient and Family Care Policy: XI-30:45 “Universal Protocol (Time Out) for Invasive Procedures Performed Outside the OR.” This policy can be found on Anchor.

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700 Children's Drive Columbus, Ohio 43205 614.722.2000