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VA National Center for Patient Safety

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Ensuring Correct Surgery

A surgeon hands a surgery tool to a helper during a surgeryHaving Surgery? Review VA's five-step "Ensuring Correct Surgery" process: We have information that will help you to understand what will happen before your surgery and how your doctors and nurses will take action to make sure that everything goes as planned. We have a five-step process that we call "Ensuring Correct Surgery."

Read our patient brochure and how find out how the process involves you!

Days to a couple hours before your surgery…

Review all the information on the Consent Form before you sign it. You, or your surrogate, must sign a consent form before any surgery can take place. It should be written in words that you can understand. If you are not sure about anything, ask. Many of your questions will be answered by reading the consent form. Here are some good questions to ask in order to better understand your surgery:

  1. What is the name of the surgery that will be done?
  2. Where or what body part will you be operating on? (Write down if it is the left or right side, if needed.)
  3. Are there any alternatives to surgery?
  4. What are the risks of this surgery?
  5. What is likely to happen if I don’t have the surgery?
  6. Who is in charge of the surgical team? (Write the name here.)
  7. About how long will it take to recover after the surgery?

The doctor or other member of the surgical team will make a mark with a pen on the part of your body where the surgery will happen. This should be done BEFORE you go into the operating room. Some doctors will sign their name or initials. Some doctors will make an “X” or “Yes” mark on the correct body part.

Check that the mark does not rub off. It will be very important for the doctors and nurses to see the mark while you are asleep just before the surgery. Tell your doctor or nurse if the mark rubs or washes off before the surgery.

An hour, or less, before the surgery...

While you are still awake, a doctor or nurse will ask you to say your name, your social security number or birth date, and the part of your body that will be operated on.

Don’t be alarmed by these questions; your doctor knows who you are. This is how they make sure they have everything right.

Just before the surgery begins...

Just before the surgery begins, everyone in the operating room will take a short “time out” and check for the last time that they have the right patient and are doing the right operation on the right body part. You may be asleep
for this part.

The doctors and nurses in the VA are taking these important steps to make sure that everything goes as planned
for your surgery.