Consent and Time Out (Final Verification) Policy

I. Principle:

Prior to the start of any invasive procedure, a consent must be signed and a final verification process (such as a “time out”) must occur to confirm the correct patient, procedure and site. Communication techniques should be active, not passive.

Invasive procedures are defined as all procedures that expose patients to more than minimal risk, including procedures such as bone marrow aspirates, therapeutic phlebotomies and fine needle aspirates. Certain routine “minor” procedures such as venipuncture are not included.

II. Procedure

1. Patient Identification and consent:

A. Inpatient

a. Before beginning the procedure, initial patient identification should be performed using the patient name and medical record number and/or birth date and matching the patient identification band and lab requisition. Refer to the “Patient Identification” policy.

b. Confirm the patient has signed the hospital consent for the procedure.

B. Outpatient

a. Before beginning the procedure, initial patient identification should be performed using the patient name and medical record number and/or birth date. Refer to the “Patient Identification” policy.

b. Explain the procedure and have the patient (or guardian) sign the UCL Consent for the procedure.

C. Following the initial patient identification a final verification procedure must be performed prior to beginning the procedure using active communication. This includes the following steps:
Note: If laboratory staff leaves the patient’s location prior to initiating the procedure, steps a., b. and c. below must be repeated.

a. The patient or the patient’s designee must verbally state patient name and birth date.

b. The patient (or designee) must verbally confirm the procedure to be performed.

c. The site of the procedure must be verified.

d. Inpatient documentation is left with the patient’s chart; outpatient documentation is filed in the laboratory.

2. Policies for specific procedures and documentation pertinent to each site are noted below.

A. Therapeutic phlebotomy: Refer to the “Therapeutic Phlebotomy” procedure.
Document patient final verification as follows:

a. Mercy (Dubuque and Dyersville) sites: Complete the Time out section on the UCL form “Universal Protocol for Procedure Verification” to verify that a hospital consent has been signed:
Patient Identification
Invasive Procedure
Site of Procedure
Signatures (Verifier and Witness)

b. Finley Site:
Complete documentation that a “time out” was performed by noting it on the patient medical record form “Time Out Checklist”:
Patient identification was confirmed.
Procedure was confirmed.

B. Fine Needle Aspirate:

a. Inpatients

1. Mercy (Dubuque and Dyersville) site:
Nursing staff documents “Time Out” procedure completed in Power Chart.

2. Finley site:
Laboratory staff documents on the “Time Out Checklist”.

b. Outpatients
Complete both the Consent portion and the Time out portion of the UCL Universal Protocol for Procedure Verification including:
Patient Identification
Physician
Invasive Procedure
Site of Procedure
Signatures (Patient, Verifier and Witness)

C. Bone Marrow

a. Mercy (Dubuque and Dyersville) site:
Nursing staff documents “Time Out” procedure completed in Power Chart.

b. Finley site:
Laboratory staff documents on the “Time Out Checklist”.

III. Reference:

1. 2007 TJC National Patient Safety Goals Requirement 1B.

i. July 2009 S. Rodriguez, R. Maiers

 

Pathologist:

Technical Director: