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Sample ASC Time-Out Policy and Procedure

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ASC Durango (Colo.) recently underwent its first AAAHC survey and achieved accreditation. During the survey, the ASC was praised for its time-out policy and procedure.


"Everyone in the room is an active participant in our time-out procedure," says Cheryl Desko, RN, clinical director for the ASC.


Below is a sample version of ASC Durango's time-out procedure you can adapt for use in your own surgery center.


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TITLE: Time out: Verification and Documentation of Surgical Patient and Procedure

Prepared By:_________________________ Authorized By:___________________

Endorsed By:_________________________ Effective Date:____________________



Policy: To promote patient safety by providing guidelines for verification of correct site, correct procedure and correct patient for surgical procedures.


Procedure: Prior to the start of ANY invasive procedure there will be confirmation of the correct site, the correct procedure and the correct patient. This will be completed in a collaborative manner by the OR team: circulating nurse, scrub tech, anesthesiologist, surgeon. No instrumentation shall be handed to the surgeon prior to the verification procedure. The OR RN will document this on the OR record. If an anesthesiologist needs to perform a treatment (e.g., a peripheral nerve block, prior to the start of the surgery in the operating room), the anesthesiologist and the RN assisting the physician must follow the verification procedure. This includes the confirmation of the correct patient, correct surgery and the correct side, verifying the patient's verbal responses with the ID band and the medical record prior to the administration of the anesthetic block.


In the Operating Room:


  1. After the patient is draped and before the start of the case, the entire surgical team must do a verbal confirmation. The patient does not have to be awake for this verbal confirmation.
  2. The OR RN will initiate the verbal confirmation. This confirmation must include the verification of the correct patient, the correct side/site, the correct procedure, the correct patient position, administration of preoperative antibiotics, and that all the essential equipment and instrumentation is available.
  3. The patient will be confirmed using two (2) patient identifiers. Preferred identifiers are the patient name and date of birth.
  4. The surgical site marking must be visible at the time of the verbal confirmation.
  5. Step 1 and 2 will be documented on the OR nursing record.


Source: ASC Durango (Colo). Adapted and reprinted with permission.

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