Community Initiatives
 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 Ohio Surgical Verification Protocol for site marking should be implemented in all facilities in the Greater Cincinnati Area. The Ohio Surgical Verification Protocol was originally created in 2004 through the efforts of the Ohio Patient Safety Institute in collaboration with The Joint Commission, Ohio hospitals, ASCs, surgeons, anesthesiologists, the State Medical Board of Ohio, and the Ohio Board of Nursing to promote one standard across the state of Ohio.

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 statewide 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. This protocol uses the JCAHO Universal Protocol as the foundation, with reference to recommendations by professional organizations. It is based on consensus from relevant clinical specialties and professional disciplines throughout Ohio.

The Ohio Surgical Verification Protocol is divided into three primary processes: Pre-operative verification, marking the operative site, and "time out" immediately prior to starting the procedure.

This protocol focuses on traditional surgical settings, and provides a template for areas where invasive procedures are performed in non-surgical settings, such as the bedside. It is recognized that the process may need to be modified in some settings; however, minimal deviation from the protocol is encouraged.

Please click here for the key findings of the survey and complete results/analysis.

 Helpful Links & Resources

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

The Ohio Surgical Verification Protocol: The full Ohio Surgical Verification Protocol endorsed and recommended by the Greater Cincinnati Health Council's Physician Impact Project Committee.

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. 

Summary Sheet PowerPoint slide for the Ohio Surgical Verification Protocol: A quick outline summary in an easy-to-follow format of the Ohio Surgical Verification Protocol. This sheet is also available in PDF Form by clicking here.

GCHC Physician Impact Committee Survey Results & Analysis: Results and analysis from the April 2008 survey distributed by the GCHC Physician Impact Committee regarding surgical site markings and time outs.

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.

Joint Commission Information: Includes information on the Joint Commission Universal Protocol, Frequently Asked Questions, Facts, and Helpful Tips. The 2008 Joint Commission Universal Protocol is based on the consensus of experts from the relevant clinical specialties and professional disciplines and is endorsed by more than 40 professional medical associations and organizations.

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.