5.1.26 Test protocol before interventions

1 Aim and purpose

Introduction of a general procedure to avoid side mix-ups, incorrect surgical procedures and surgeries for the wrong patient

2 Scope of application

All surgical procedures under anaesthesia or sedation:

• Single organ surgery, caesarean section, heart surgery
• Interventional procedures where the side is not predetermined. However, there should be a preferred side in the facility. In most cases, this is unavoidable for equipment or other technical reasons. If it is necessary to deviate from this for certain reasons, this should be communicated at the time of registration and then with appropriate information on the documents.
• Teeth: Mark teeth in the documentation and on the x-rays
• Premature babies. In them, the dye can lead to permanent colour particle retention.

3 Description

3.1 Verification of identity before the operation

The identity of the patient, the surgical procedure and possibly the side to be operated on must be checked on the following occasions: - at the time of being called to the operating theatre - at the time of arrival in the operating theatre - at the time of transfer of responsibility for the patient from another practitioner - at the time of leaving the pre-operative waiting area and/or when moving to the operating theatre. If possible, the patient should be involved in the identification process. To this end, the patient should be addressed by name and told what is planned. At the same time, the patient should be reassured that their identity is known.

3.2 Completeness of the documents

Before the operation, it must be checked that - the medical file and the consent form are available. - the X-ray images important for the operation are correctly labelled and hung up on the light box in the operating theatre - the implants and special equipment are available

3.3 Marking the surgical site

- The surgical site should be marked. Other markings should be omitted unless this is essential for the procedure itself. - The marking must be unambiguous. The incision is usually marked - The marking should be labelled with the surgeon's name and signed. - The surgeon should mark the surgical site preoperatively during the personal presentation to the patient. - The marking must also be recognisable after skin disinfection and draping. - The procedure should be defined for the entire department, preferably for the entire hospital. - As a minimum, all surgical areas must be labelled in the case of paired organs or multiple sites such as hands, legs, fingers, toes or the height of the access point for vertebral bodies. - If possible, the patient should be involved in the labelling. - It should be determined how to proceed if a patient refuses to be labelled.

3.4 Time-out immediately before the operation

Before the procedure begins, the time-out is formally called and the following is checked and the result recorded in a checklist: - The patient's identity has been verified - Informed consent for the planned procedure has been obtained - The correct side and surgical site have been selected. - The implants required for the procedure are available - Instruments and materials are available. - The patient is correctly positioned.

3.5 Procedures outside the operating theatre and on the ward

Procedures on the ward can only deviate from the procedure described above if the procedure is carried out by someone who remains the same from the decision to the execution and there is no significant time gap. Everyone should take time out before starting the procedure!

4 Documentation

Checklist for preparation, induction and time-out on time-out protocol

5 Resources

Time required

Marking during the surgeon's visit: three minutes Time-out during surgery: a few seconds

6 Responsibility

The person accepting a patient checks the patient's identity on the documents provided

7 Notes and comments

8 Applicable documents

8.1 Literature

Universal Protocol of the Joint Commission

8.2 Terms

9 Systems