This document outlines various hospital protocols and procedures related to patient safety, including ensuring correct patient identification, preventing wrong site/procedure errors, and proper handling of blood products. It discusses the surgical safety checklist that must be performed before procedures, including sign in, time out, and sign out steps. Site marking protocol and exemptions are covered. Risk assessment for venous thromboembolism is also mentioned.

1. Joven Botin Bilbao, RN, MAN
Deputy Chief Nurse Officer
Clinical and Accreditation Educator

2. QM.17
The hospital
has a process
to ensure
correct
identification
of patients.

4. “can you tell me your name and
address” “are you Ahmed Saeed Saleh
Alqahtani”,

5. Q.M. 18
The hospital has a
process to prevent
wrong patient,
wrong site,
and wrong
surgery/procedure.

6. A Surgical Safety Checklist Should Be Done
For At Least:
 Procedures that investigate and/or treat
diseases and disorders of the human body
through cutting, removing, altering, or insertion
of diagnostic /therapeutic scopes.
 The Sign In, Sign Out, and Time Out applies to
a location in the hospital where these
procedures are performed, and it must be done
just before starting the procedure which
involves the entire operative team.

7. Protocol :
Pre-operative verification
process
Marking of the precise site of
procedure/surgery
A time-out that is held
immediately before the start of
any procedure/Surgery.

8. Pre-operative Checklist
Will be initiated the day before the
surgery unless the procedure is an
emergency.

9. Surgical Site Marking :
 Involve the patient
 Done with an instantly recognize mark “X”
 Be consistent throughout the hospital
 Be made by the person performing the
procedure
 Take place with the patient awake and
aware, if possible.
 Be visible after the patient is prepped and
draped.
 Marked in all cases involving laterality,
multiple structures (fingers, toes, lesions), or
multiple levels (spine)

10. Exemption of marking the
surgical site:
 Single organ
 Interventional cases for which the
catheter/instruments insertion site is not
predetermined.
 Teeth-But, indicate operative tooth name(s) on
documentation.
 Premature infants, for whom the mark may
cause a permanent tattoo.

11. The Sign In process:
 To verify the correct site, procedure, and
patient
 To confirm Informed Consent is obtained.
 Identify site by marking.
 Pre anesthesia assessment done
 Pulse oximeter on patient and
functioning.
 Diagnostic and radiologic test result is
available
 Known allergy.
 Difficult Airway/Aspiration risk.
 Crossmatching done.

12. Time Out




13. Sign out
 The performed procedure have to be recorded.
 Confirmed that the count complete
 Specimen identified and labeled
 Any equipment problems.
 Post operative management in the recovery area.

14. PC.25
Policies And
Procedures
Guide The
Handling,
Use, and
Administration Of
Blood And Blood
Products.

16. ”Transfusion without NAT testing".
 Two staff members



17. P.C. 26
Patients at
risk for
developing
venous
thromboembol
ism are
identified and
managed.

18. ADULT VENOUS
THROMBOEMBOLISM RISK ASSESSMENT TOOL.


19. ( Chemical and
Mechanical)SHOULD

21. Thank You