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Ensuring Correct Surgery


Doctors in the operating room under bright lights. Incorrect surgical procedures or incorrect diagnostic and therapeutic invasive procedures are relatively uncommon adverse medical events, but often devastating when they occur.

To prevent or avoid such adverse medical events, NCPS developed a straightforward, five-step process to identify the correct patient, mark the correct surgical site, and ensure the correct procedure is performed.

Instituted in 2002 for surgical procedures inside the operating room, the Ensuring Correct Surgery Directive was modified in 2004 to also address invasive procedures outside the operating room.

The original version contributed to the development of the Joint Commission’s Universal Protocol for Correct Site Surgery, which took effect July 2004.

Analyses prior to launching the initial five-step process revealed the problem of incorrect surgery to be far more complex than previously thought. It wasn’t just a series of left-right mix-ups; NCPS found that 36 percent of all incorrect surgeries were surgical procedures conducted on the wrong patient.

That’s why patient identification is a major part of the five-step process.

The Five Steps

Step 1– Consent Form (days or hours before surgery). It must include:

  • Patient’s full name.
  • Procedure site.
  • Name of procedure.
  • Reason for procedure.

Step 2 – Mark the Site (days or hours before surgery). The operative site must be marked by a physician or other privileged provider who is a member of the operating team.

Step 3 – Patient Identification (just before entering the operating room). The operating room staff will ask the patient to state (NOT confirm):

  • Their full name.
  • Full Social Security Number or date of birth.
  • Site for the procedure.

Responses will be checked against the marked site, ID band, consent form, and other documents.

Step 4 – “Time Out” (immediately prior to surgery). Conducted within the operating room when the patient is present and prior to beginning procedure, the operating room staff must verbally confirm through a time out:

  • Presence of the correct patient.
  • Marking of the correct site.
  • Procedure to be preformed.
  • Availability of the correct implant.

Step 5 – Imaging Data. If imaging data is used to confirm the surgical site, two or more members of the operating room team must confirm the images are correct and properly labeled.

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Ensuring Correct Surgery