Procedural Checklist November 2018
Surgical Safety Checklist September 2018
Procedural Guide for Universal Protocol Applicability.
Universal Protocol includes the pre-procedure verification, site marking (if applicable) and time-out conversation.
General Inclusions:
* All operative and other invasive procedures that expose patients to more than minimal risk. This includes most procedures that involve puncture or incision of the skin, insertion of an instrument or foreign material into the body.
* All procedures performed in the main operating rooms, cardiac catheterization and electrophysiology labs, endoscopy suites, bronchoscopy suites, and interventional radiology.
* All inpatient and ambulatory facilities (including FPA).
General Exclusions: The following examples are procedures that are excluded:
* Venipuncture, peripheral arterial line placement (radial), intravenous line placement, urinary catheter placement, nasogastric tube placement, arterial blood gas
* Extremely rare occasions when procedures are performed under immediately life-threatening situations (although UP including a time out should be performed whenever possible).
Non-Operating Room Locations:
The following are examples of procedures that require universal protocol in Non-Operating Room locations (floor, ICU, offices). This list is not all-inclusive. Last updated 10.8.2019
* Percutaneous aspiration of body fluids through the skin (not including joint spaces see below) (e.g., bone marrow aspiration, lumbar puncture, paracentesis, thoracentesis, suprapubic catheterization)
* Biopsy/removal of tissue (e.g. solid organ, muscle, skin, bone marrow)
* Removal of permanent catheter, port, or device. (e.g. portacath removal, pacemaker removal, tunneled catheter removal).
* Cardiac procedures (e.g., cardiac catheterization, cardiac pacemaker implantation, angioplasty, stent implantation)
* Central (axillary, femoral, internal jugular, carotid) vascular access device insertion (e.g., Central venous and arterial catheter placement, pulmonary artery catheter placement, Hickman catheter, dialysis catheter placement, temporary pacemaker wire)
* ECT
* Endoscopy (e.g., colonoscopy, bronchoscopy, esophagogastric endoscopy, cystoscopy, percutaneous endoscopic gastrostomy (PEG) or recent gastrostomy-tube (including PEG) exchange, J-tube placements, nephrostomy tube placements, and flex sigmoidoscopy)
* Invasive radiology procedures (e.g., cardiac and peripheral vessel angiography, angioplasty, percutaneous biopsy)
* Laser therapy or electrocautery of lesion (e.g. eye, skin, gynecology, and otolaryngology)
* Dermatology procedures (biopsy, excision and deep cryotherapy for malignant lesions)
* Invasive ophthalmic procedures, including miscellaneous procedures involving implants
* Oral surgical procedures (e.g. tooth extraction, gingival biopsy)
* Podiatric invasive procedures (removal of ingrown toenail, etc.)
* Regional nerve block (e.g. for pain control, surgical procedure)
* Gynecology procedures (colposcopy with biopsy, cervical cone biopsy, cervical cryoablation, endometrial biopsy, hysteroscopy diagnostic or operative, dilatation and curettage, hysterosalpingogram, IUD insertion)
* Urologic procedures (e.g. ureteral stent placement, circumcision)
* Vascular surgery (e.g. sclerotherapy, radiofrequency venous ablation, wound debridement)
* Anoscopy/proctoscopy with possible biopsy
Universal protocol is not required in Non-Operating room locations for the following procedures:
* Dialysis
* IV contrast for CT scan if a process for ensuring review of allergies and proper imaging is in place (questionnaire, other process).
* PICC line insertion/midline insertion.
* Aspiration of a joint space /bursa or injections of any substance into a joint space/bursa as patients in the office are usually awake and can participate
* Exercise and nuclear stress testing
* Trigger point injections
* Minor nerve blocks performed in the office (e.g. blocks for dental procedures such as inferior alveolar, infra-orbital, supra-orbital, greater palatine, nasopalatine, posterior superior alveolar, occipital, lateral femoral cutaneous nerve)
* Incision and drainage
* Closed reduction of fractures
* Umbilical vein/artery catheters
* Removal of PEG
* Flourescein angiograms
* Removal of removal of chest tube, removal of JP drain
* Diagnostic transoral and transnasal endoscopy without biopsy
* Diagnostic rigid anoscopy/proctoscopy without biopsy
* Mayfield pinning
* Hemorrhoid procedures such as: excision/incision of thromboses hemorrhoid/banding/infrared and electrocautery, coagulation/silver nitrate application
* Anal pap
* Topical treatment of anal warts
* Anal/rectal ultrasound, anal manometry
* Rectal Exam