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 Resource Center for Surgical Site Markings & Time Outs
Introduction & Purpose

Within the practice of Universal Protocol, site marking and taking a clinical “time out” are key factors in providing safe care. In April 2008, the Greater Cincinnati Health Council's Physician Impact Committee distributed a survey to area member hospitals to gauge the effectiveness of surgical site markings and time outs, and staff members from 13 Cincinnati area hospitals responded to the survey. Based on that survey to Cincinnati area hospital members, the committee discovered that only four respondents polled were aware of the Ohio Hospital Association's recommendations Time Outregarding surgical site markings and time outs. Respondents consisted of OR staff, hospital leadership and physicians, and the survey results also noted a high degree of variability in practice and professional accountability for site marking and “time out.”


GCHC Physician Impact Committee Recommendations

Define the correct protocol and practice. Uniform physician focused education incorporating the 2009 Joint Commission Universal Protocol for site marking should be implemented in all facilities in the Greater Cincinnati Area. The Universal Protocol was revised based on feedback received at the Wrong Site Surgery Summit in 2007.

Impose a penalty for non-compliance. Hospital administration and physician leadership should agree to classify a failure to comply with the site marking requirements of Universal Protocol and verified the process for “time-out” as an error in care delivery.

Monitor compliance observation. Practice observations have yielded the greatest compliance.

Wrong site, wrong procedure, and wrong person surgery/procedure can be prevented, and this universal protocol is intended to achieve that goal. The GCHC Physician Impact Committee recommends that all GCHC facilities and professionals involved with surgery or procedures in all settings are asked to incorporate the following protocol to facilitate continuity and reduce variance across settings, thereby reducing or eliminating the possibilities for error.

Please click here for the full Physician Impact Project Recommendations.

 Helpful Links & Resources

Resource Center for the GCHC Physician Impact Committee and information pertaining to the Ohio Surgical Verification Protocol

Joint Commission Information: Includes information on the Joint Commission Universal Protocol, Frequently Asked Questions, Facts, and Helpful Tips. The 2009 Joint Commission Universal Protocol was revised based on feedback received at the Wrong Site Surgery Summit in 2007.

The Joint Commission 2009 Universal Protocol and 2004 Ohio Surgical Verification Protocol Comparison Guide: A quick-reference guide outlining additions and modifications to the 2009 Joint Commission Universal Protocol as compared to the 2004 Ohio Surgical Verification Protocol.

Ohio Patient Safety Institute: The Ohio Patient Safety Institute (OPSI) is an organization dedicated to improving patient safety in Ohio. The Institute is a subsidiary of the Ohio Health Council, which was founded by the Ohio Hospital Association, the Ohio State Medical Association, and the Ohio Osteopathic Association. Through this collaboration and common effort, OPSI has the ability to work with over 180 hospitals and 9,000 physicians in Ohio to improve patient safety for all Ohioans. 

Audit & Assessment Form: An assessment form that can be used for quick procedure audits regarding surgical site markings and time outs.

Time Out Poster: The GCHC Physician Impact Committee recommends distributing this poster throughout your facility to help ensure patient safety through surgical site markings and time outs.

2008 National Time Out Day Information: A poster and a press release from the Association of Perioperative Registered Nurses highlighting June 18, 2008 as this year's annual National Time Out Day.

Can Your Nurses Stop a Surgeon? An article by Matthew Weinstock that first appeared in the September 2007 issue of H&HN Magazine that highlights some of the challenges facing today's nurses regarding surgical site markings and time outs.