Preoperative Protocols
• Hospitals should develop and implement policies and procedures to ensure there are at least three independent verifications of the surgical site, location, and patient.
• The attending physician should sign the consent form prior to the induction of anesthesia and confirm the accuracy of the document including the description of the procedure.
• As one of the three independent verifications, it is recommended that the surgeon of record mark or unequivocally identify the site and/or side prior to surgery. The marking technique should be determined by the facility.
• Whenever possible, the surgeon of record or his/her designee, should physically see and talk to the patient in the perioperative area on the day of surgery.
• When laterality (the procedure is specific to one side of the body) is at issue, the words should be spelled out in their entirety, on the operative schedule and the operative consent form.
• The anticipated level(s) for spinal surgery should be indicated on the operative schedule and the operative consent form. Levels may be modified later if operative findings indicate differences.
• For operating room settings (for other settings, use appropriate personnel), the circulating nurse will ensure:
— the correct patient is present;
— the consent has been signed by the surgeon of record on the day of surgery;
— the appropriate surgical side/site has been identified/marked;
— the surgeon has selected for display appropriate and relevant radiological films for the planned procedure (the surgeon of record determines what is appropriate and relevant);
— there is agreement as to the planned procedure, which has been verified with the surgeon, anesthesia personnel, and circulating nurses. The agreement must be documented in the medical record.
Source: The New York State Department of Health, Albany. Web: www.health.state.ny.us/nysdoh/commish/2001/preop.htm.
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