Class Subject: Performance Improvement (Healthcare Information Management)

 Hospital D is a 400-bed acute-care facility with a wide range of services. Dr. Jones is a cardio-thoracic surgeon at the facility and has been practicing in the area for the past six years. Dr. Jones is performing a coronary bypass procedure on a 59-year-old patient. Although the procedure is going well, it took more time than usual to complete because, prior to beginning, the anesthesiologist needed extra time to ensure a safe experience with the anesthesia due to the patient’s asthma and sleep apnea. The operating rooms at the hospital have been especially busy lately with a high number of unexpected trauma surgeries along with the already busy schedule the operating room tends to have. Dr. Jones is preparing to finish the procedure and “close up” the patient when he notices another physician standing at the window in the door leading into the operating room. The physician is a seasoned physician that has been at the hospital for several decades. The physician not only looks through the window at Dr. Jones, but lifts his arm and taps on his watch as a way to tell Dr. Jones that his surgery time has gone past what is scheduled. Although Dr. Jones is a confident and competent surgeon, this experience really rattles him a little and he finds himself somewhat distracted by the other physician’s behavior. He let himself become a little “short fused” with the staff in the room and begins to speed up his work, pressuring the other staff. Dr. Jones has the patient return to his office with pain and issues in his incision. After further workup, it is determined that a sponge was left in during the procedure. 

Tasks:

• Identify performance improvement issues based on the description of the issue and provide a brief description. (15 points)
• Explain the issue based on the systems thinking approach. (15 points)
• Identify at least 1 indicator that the hospital may use to monitor such issues (surgical errors and alike) along with how that indicator will be measured. (15 points) 
• Suggest one QI Toolbox technique that may be used to improve the OR processes (flowchart, check sheet, or any other appropriate tools) and explain why that technique would be helpful. (15 points) 
• Identify the TJC NPSG standard(s) that the hospital OR physicians and staff should be guided by. (complete NPSG is available in the Files area). (10 points) 

Goal 1
Improve the accuracy of patient identification.

NPSG.01.01.01

Use at least two patient identifiers when providing care, treatment, and services.

–Rationale for NPSG.01.01.01–

Wrong-patient errors occur in virtually all stages of diagnosis and treatment. The intent for this goal is two-
fold: first, to reliably identify the individual as the person for whom the service or treatment is intended;
second, to match the service or treatment to that individual. Acceptable identifiers may be the individual’s
name, an assigned identification number, telephone number, or other person-specific identifier.

Newborns are at higher risk of misidentification due to their inability to speak and lack of distinguishable
features. In addition to well-known misidentification errors such as wrong patient/wrong procedure,
misidentification has also resulted in feeding a mother’s expressed breastmilk to the wrong newborn, which
poses a risk of passing bodily fluids and potential pathogens to the newborn. A reliable identification system
among all providers is necessary to prevent errors.

Element(s) of Performance for NPSG.01.01.01

1. Use at least two patient identifiers when administering medications, blood, or blood components; when
collecting blood samples and other specimens for clinical testing; and when providing treatments or
procedures. The patient’s room number or physical location is not used as an identifier.
(See also MM.05.01.09, EPs 7, 10; PC.02.01.01, EP 10)

2. Label containers used for blood and other specimens in the presence of the patient.
(See also PC.02.01.01, EP 10)

3. Use distinct methods of identification for newborn patients.
Note: Examples of methods to prevent misidentification may include the following:
– Distinct naming systems could include using the mother’s first and last names and the newborn’s
gender (for example, “Smith, Judy Girl” or “Smith, Judy Girl A” and “Smith, Judy Girl B” for multiples).
– Standardized practices for identification banding (for example, using two body sites and/or bar coding
for identification).
– Establish communication tools among staff (for example, visually alerting staff with signage noting
newborns with similar names).

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Goal 2
Improve the effectiveness of communication among caregivers.

NPSG.02.03.01

Report critical results of tests and diagnostic procedures on a timely basis.

–Rationale for NPSG.02.03.01–

Critical results of tests and diagnostic procedures fall significantly outside the normal range and may indicate
a life-threatening situation. The objective is to provide the responsible licensed caregiver these results within
an established time frame so that the patient can be promptly treated.

Element(s) of Performance for NPSG.02.03.01

1. Develop written procedures for managing the critical results of tests and diagnostic procedures that
address the following:
– The definition of critical results of tests and diagnostic procedures
– By whom and to whom critical results of tests and diagnostic procedures are reported
– The acceptable length of time between the availability and reporting of critical results of tests and
diagnostic procedures

2. Implement the procedures for managing the critical results of tests and diagnostic procedures.

3. Evaluate the timeliness of reporting the critical results of tests and diagnostic procedures.

Goal 3
Improve the safety of using medications.

NPSG.03.04.01

Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other
procedural settings.
Note: Medication containers include syringes, medicine cups, and basins.

–Rationale for NPSG.03.04.01–

Medications or other solutions in unlabeled containers are unidentifiable. Errors, sometimes tragic, have
resulted from medications and other solutions removed from their original containers and placed into
unlabeled containers. This unsafe practice neglects basic principles of safe medication management, yet it is
routine in many organizations.

The labeling of all medications, medication containers, and other solutions is a risk-reduction activity
consistent with safe medication management. This practice addresses a recognized risk point in the
administration of medications in perioperative and other procedural settings. Labels for medications and
medication containers are also addressed at Standard MM.05.01.09.

Element(s) of Performance for NPSG.03.04.01

1. In perioperative and other procedural settings both on and off the sterile field, label medications and
solutions that are not immediately administered. This applies even if there is only one medication
being used.
Note: An immediately administered medication is one that an authorized staff member prepares or
obtains, takes directly to a patient, and administers to that patient without any break in the process.
Refer to NPSG.03.04.01, EP 5, for information on timing of labeling.

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2. In perioperative and other procedural settings both on and off the sterile field, labeling occurs when
any medication or solution is transferred from the original packaging to another container.

3. In perioperative and other procedural settings both on and off the sterile field, medication or solution
labels include the following:
– Medication or solution name
– Strength
– Amount of medication or solution containing medication (if not apparent from the container)
– Diluent name and volume (if not apparent from the container)
– Expiration date when not used within 24 hours
– Expiration time when expiration occurs in less than 24 hours
Note: The date and time are not necessary for short procedures, as defined by the hospital.

4. Verify all medication or solution labels both verbally and visually. Verification is done by two individuals
qualified to participate in the procedure whenever the person preparing the medication or solution is
not the person who will be administering it.

5. Label each medication or solution as soon as it is prepared, unless it is immediately administered.
Note: An immediately administered medication is one that an authorized staff member prepares or
obtains, takes directly to a patient, and administers to that patient without any break in the process.

6. Immediately discard any medication or solution found unlabeled.

7. Remove all labeled containers on the sterile field and discard their contents at the conclusion of the
procedure.
Note: This does not apply to multiuse vials that are handled according to infection control practices.

8. All medications and solutions both on and off the sterile field and their labels are reviewed by entering
and exiting staff responsible for the management of medications.

NPSG.03.05.01

Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.
Note: This requirement does not apply to routine situations in which short-term prophylactic anticoagulation is used for
preventing venous thromboembolism (for example, related to procedures or hospitalization).

–Rationale for NPSG.03.05.01–

Anticoagulation therapy can be used as therapeutic treatment for several conditions, the most common of
which are atrial fibrillation, deep vein thrombosis, pulmonary embolism, and mechanical heart valve implant.
However, it is important to note that anticoagulant medications are more likely than others to cause harm due
to complex dosing, insufficient monitoring, and inconsistent patient compliance. This National Patient Safety
Goal has great potential to positively impact the safety of patients on this class of medications, including
improving patient outcomes.

To achieve better patient outcomes, patient education is a vital component of an anticoagulation therapy
program. Effective anticoagulation education includes face-to-face interaction with a trained professional who
works closely with patients to be sure that they understand the risks involved with anticoagulation therapy
and the precautions they need to take. The use of standardized practices for anticoagulation therapy that
include patient involvement can reduce the risk of adverse drug events associated with heparin
(unfractionated), low molecular weight heparin, warfarin, and direct oral anticoagulants (DOACs).

Element(s) of Performance for NPSG.03.05.01

1. The hospital uses approved protocols and evidence-based practice guidelines for the initiation and
maintenance of anticoagulant therapy that address medication selection; dosing, including
adjustments for age and renal or liver function; drug–drug and drug–food interactions; and other risk
factors as applicable.

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2. The hospital uses approved protocols and evidence-based practice guidelines for reversal of
anticoagulation and management of bleeding events related to each anticoagulant medication.

3. The hospital uses approved protocols and evidence-based practice guidelines for perioperative
management of all patients on oral anticoagulants.
Note: Perioperative management may address the use of bridging medications, timing for stopping an
anticoagulant, and timing and dosing for restarting an anticoagulant.

4. The hospital has a written policy addressing the need for baseline and ongoing laboratory tests to
monitor and adjust anticoagulant therapy.
Note: For all patients receiving warfarin therapy, use a current international normalized ratio (INR) to
monitor and adjust dosage. For patients on a direct oral anticoagulant (DOAC), follow evidence-based
practice guidelines regarding the need for laboratory testing.

5. The hospital addresses anticoagulation safety practices through the following:
– Establishing a process to identify, respond to, and report adverse drug events, including adverse
drug event outcomes
– Evaluating anticoagulation safety practices, taking actions to improve safety practices, and
measuring the effectiveness of those actions in a time frame determined by the hospital

6. The hospital provides education to patients and families specific to the anticoagulant medication
prescribed, including the following:
– Adherence to medication dose and schedule
– Importance of follow-up appointments and laboratory testing (if applicable)
– Potential drug–drug and drug–food interactions
– The potential for adverse drug reactions

7. The hospital uses only oral unit-dose products, prefilled syringes, or premixed infusion bags when
these types of products are available.
Note: For pediatric patients, prefilled syringe products should be used only if specifically designed for
children.

8. When heparin is administered intravenously and continuously, the hospital uses programmable pumps
in order to provide consistent and accurate dosing.

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Introduction to Reconciling Medication Information
The large number of people receiving health care who take multiple medications and the
complexity of managing those medications make medication reconciliation an important safety
issue. In medication reconciliation, a clinician compares the medications a patient should be using
(and is actually using) to the new medications that are ordered for the patient and resolves any
discrepancies.

The Joint Commission recognizes that organizations face challenges with medication reconciliation.
The best medication reconciliation requires a complete understanding of what the patient was
prescribed and what medications the patient is actually taking. It can be difficult to obtain a
complete list from every patient in an encounter, and accuracy is dependent on the patient’s ability
and willingness to provide this information. A good faith effort to collect this information is
recognized as meeting the intent of the requirement. As health care evolves with the adoption of
more sophisticated systems (such as centralized databases for prescribing and collecting
medication information), the effectiveness of these processes will grow.

This National Patient Safety Goal (NPSG) focuses on the risk points of medication reconciliation.
The elements of performance in this NPSG are designed to help organizations reduce negative
patient outcomes associated with medication discrepancies. Some aspects of the care process that
involve the management of medications are addressed in the standards rather than in this goal.
These include coordinating information during transitions in care both within and outside of the
organization (PC.02.02.01), patient education on safe medication use (PC.02.03.01), and
communications with other providers (PC.04.02.01).

In settings where medications are not routinely prescribed or administered, this NPSG provides
organizations with the flexibility to decide what medication information they need to collect based
on the services they provide to patients. It is often important for clinicians to know what medications
the patient is taking when planning care, treatment, and services, even in situations where
medications are not used.

NPSG.03.06.01

Maintain and communicate accurate patient medication information.

–Rationale for NPSG.03.06.01–

There is evidence that medication discrepancies can affect patient outcomes. Medication reconciliation is
intended to identify and resolve discrepancies—it is a process of comparing the medications a patient is
taking (or should be taking) with newly ordered medications. The comparison addresses duplications,
omissions, and interactions, and the need to continue current medications. The types of information that
clinicians use to reconcile medications include (among others) medication name, dose, frequency, route, and
purpose. Organizations should identify the information that needs to be collected in order to reconcile current
and newly ordered medications and to safely prescribe medications in the future.

Element(s) of Performance for NPSG.03.06.01

1. Obtain information on the medications the patient is currently taking when he or she is admitted to the
hospital or is seen in an outpatient setting. This information is documented in a list or other format that
is useful to those who manage medications.
Note 1: Current medications include those taken at scheduled times and those taken on an as-needed
basis. See the Glossary for a definition of medications.
Note 2: It is often difficult to obtain complete information on current medications from a patient. A good
faith effort to obtain this information from the patient and/or other sources will be considered as
meeting the intent of the EP.

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2. Define the types of medication information (for example, name, dose, route, frequency, purpose) to be
collected in non-24-hour settings.
Note: Examples of non-24-hour settings include the emergency department, primary care, outpatient
radiology, ambulatory surgery, and diagnostic settings.

3. Compare the medication information the patient brought to the hospital with the medications ordered
for the patient by the hospital in order to identify and resolve discrepancies.
Note: Discrepancies include omissions, duplications, contraindications, unclear information, and
changes. A qualified individual, identified by the hospital, does the comparison. (See also
HR.01.06.01, EP 1)

4. Provide the patient (or family, caregiver, or support person as needed) with written information on the
medications the patient should be taking when he or she is discharged from the hospital or at the end
of an outpatient encounter (for example, name, dose, route, frequency, purpose).

5. Explain the importance of managing medication information to the patient when he or she is
discharged from the hospital or at the end of an outpatient encounter.
Note: Examples include instructing the patient to give a list to his or her primary care physician; to
update the information when medications are discontinued, doses are changed, or new medications
(including over-the-counter products) are added; and to carry medication information at all times in the
event of emergency situations. (For information on patient education on medications, refer to
Standards MM.06.01.03, PC.02.03.01, and PC.04.01.05.)

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Goal 6
Reduce patient harm associated with clinical alarm systems.

NPSG.06.01.01

Improve the safety of clinical alarm systems.

–Rationale for NPSG.06.01.01–

Clinical alarm systems are intended to alert caregivers of potential patient problems, but if they are not
properly managed, they can compromise patient safety. This is a multifaceted problem. In some situations,
individual alarm signals are difficult to detect. At the same time, many patient care areas have numerous
alarm signals and the resulting noise and displayed information tends to desensitize staff and cause them to
miss or ignore alarm signals or even disable them. Other issues associated with effective clinical alarm
system management include too many devices with alarms, default settings that are not at an actionable
level, and alarm limits that are too narrow. These issues vary greatly among hospitals and even within
different units in a single hospital.

There is general agreement that this is an important safety issue. Universal solutions have yet to be
identified, but it is important for a hospital to understand its own situation and to develop a systematic,
coordinated approach to clinical alarm system management. Standardization contributes to safe alarm
system management, but it is recognized that solutions may have to be customized for specific clinical units,
groups of patients, or individual patients. This NPSG focuses on managing clinical alarm systems that have
the most direct relationship to patient safety.
Note: Additional information on alarm safety can be found on the AAMI website
https://www.aamifoundation.org/coalitions/clinical-alarm-systems/complementary-research/.

Element(s) of Performance for NPSG.06.01.01

1. Leaders establish alarm system safety as a hospital priority.

2. Identify the most important alarm signals to manage based on the following:
– Input from the medical staff and clinical departments
– Risk to patients if the alarm signal is not attended to or if it malfunctions
– Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm
fatigue
– Potential for patient harm based on internal incident history
– Published best practices and guidelines
(For more information on managing medical equipment risks, refer to Standard EC.02.04.01)

3. Establish policies and procedures for managing the alarms identified in EP 2 above that, at a
minimum, address the following:
– Clinically appropriate settings for alarm signals
– When alarm signals can be disabled
– When alarm parameters can be changed
– Who in the organization has the authority to set alarm parameters
– Who in the organization has the authority to change alarm parameters
– Who in the organization has the authority to set alarm parameters to “off”
– Monitoring and responding to alarm signals
– Checking individual alarm signals for accurate settings, proper operation, and detectability
(For more information, refer to Standard EC.02.04.03)

4. Educate staff and licensed independent practitioners about the purpose and proper operation of alarm
systems for which they are responsible.

© 2020 The Joint Commission
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Goal 7
Reduce the risk of health care–associated infections.

NPSG.07.01.01

Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines and/or the
current World Health Organization (WHO) hand hygiene guidelines.

–Rationale for NPSG.07.01.01–

According to the Centers for Disease Control and Prevention, each year, millions of people acquire an
infection while receiving care, treatment, and services in a health care organization. Consequently, health
care–associated infections (HAIs) are a patient safety issue affecting all types of health care organizations.
One of the most important ways to address HAIs is by improving the hand hygiene of health care staff.
Compliance with the World Health Organization (WHO) or Centers for Disease Control and Prevention (CDC)
hand hygiene guidelines will reduce the transmission of infectious agents by staff to patients, thereby
decreasing the incidence of HAIs. To ensure compliance with this National Patient Safety Goal, an
organization should assess its compliance with the CDC and/or WHO guidelines through a comprehensive
program that provides a hand hygiene policy, fosters a culture of hand hygiene, monitors compliance, and
provides feedback.

Element(s) of Performance for NPSG.07.01.01

1. Implement a program that follows categories IA, IB, and IC of either the current Centers for Disease
Control and Prevention (CDC) or the current World Health Organization (WHO) hand hygiene
guidelines. (See also IC.01.04.01, EP 1)

2. Set goals for improving compliance with hand hygiene guidelines. (See also IC.03.01.01, EP 1)

3. Improve compliance with hand hygiene guidelines based on established goals.

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NPSG.15.01.01

Reduce the risk for suicide.
Note: EPs 2–7 apply to patients in psychiatric hospitals or patients being evaluated or treated for behavioral health
conditions as their primary reason for care. In addition, EPs 3–7 apply to all patients who express suicidal ideation
during the course of care.

–Rationale for NPSG.15.01.01–

Suicide of a patient while in a staffed, round-the-clock care setting is a frequently reported type of sentinel
event. Identification of individuals at risk for suicide while under the care of or following discharge from a
health care organization is an important step in protecting these at-risk individuals.

Element(s) of Performance for NPSG.15.01.01

1. For psychiatric hospitals and psychiatric units in general hospitals: The hospital conducts an
environmental risk assessment that identifies features in the physical environment that could be used
to attempt suicide; the hospital takes necessary action to minimize the risk(s) (for example, removal of
anchor points, door hinges, and hooks that can be used for hanging).

For nonpsychiatric units in general hospitals: The organization implements procedures to mitigate the
risk of suicide for patients at high risk for suicide, such as one-to-one monitoring, removing objects that
pose a risk for self-harm if they can be removed without adversely affecting the patient’s medical care,
assessing objects brought into a room by visitors, and using safe transportation procedures when
moving patients to other parts of the hospital.
Note: Nonpsychiatric units in general hospitals do not need to be ligature resistant. Nevertheless,
these facilities should routinely assess clinical areas to identify objects that could be used for self-harm
and remove those objects, when possible, from the area around a patient who has been identified as
high risk for suicide. This information can be used for training staff who monitor high-risk patients (for
example, developing checklists to help staff remember which equipment should be removed when
possible).

2. Screen all patients for suicidal ideation who are being evaluated or treated for behavioral health
conditions as their primary reason for care using a validated screening tool.
Note: The Joint Commission requires screening for suicidal ideation using a validated tool starting at
age 12 and above.

3. Use an evidence-based process to conduct a suicide assessment of patients who have screened
positive for suicidal ideation. The assessment directly asks about suicidal ideation, plan, intent, suicidal
or self-harm behaviors, risk factors, and protective factors.
Note: EPs 2 and 3 can be satisfied through the use of a single process or instrument that
simultaneously screens patients for suicidal ideation and assesses the severity of suicidal ideation.

4. Document patients’ overall level of risk for suicide and the plan to mitigate the risk for suicide.

5. Follow written policies and procedures addressing the care of patients identified as at risk for suicide.
At a minimum, these should include the following:
– Training and competence assessment of staff who care for patients at risk for suicide
– Guidelines for reassessment
– Monitoring patients who are at high risk for suicide

6. Follow written policies and procedures for counseling and follow-up care at discharge for patients
identified as at risk for suicide.

7. Monitor implementation and effectiveness of policies and procedures for screening, assessment, and
management of patients at risk for suicide and take action as needed to improve compliance.

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The hospital identifies safety risks inherent in its patient population.

Goal 15

Introduction to the Universal Protocol for Preventing Wrong Site, Wrong
Procedure, and Wrong Person Surgery™
The Universal Protocol applies to all surgical and nonsurgical invasive procedures. Evidence indicates that
procedures that place the patient at the most risk include those that involve general anesthesia or deep
sedation, although other procedures may also affect patient safety. Hospitals can enhance safety by correctly
identifying the patient, the appropriate procedure, and the correct site of the procedure.

The Universal Protocol is based on the following principles:
– Wrong-person, wrong-site, and wrong-procedure surgery can and must be prevented.
– A robust approach using multiple, complementary strategies is necessary to achieve the goal of always
conducting the correct procedure on the correct person, at the correct site.
– Active involvement and use of effective methods to improve communication among all members of the
procedure team are important for success.
– To the extent possible, the patient and, as needed, the family are involved in the process.
– Consistent implementation of a standardized protocol is most effective in achieving safety.

The Universal Protocol is implemented most successfully in hospitals with a culture that promotes teamwork
and where all individuals feel empowered to protect patient safety. A hospital should consider its culture
when designing processes to meet the Universal Protocol. In some hospitals, it may be necessary to be
more prescriptive on certain elements of the Universal Protocol or to create processes that are not
specifically addressed within these requirements.

Hospitals should identify the timing and location of the preprocedure verification and site marking based on
what works best for their own unique circumstances. The frequency and scope of the preprocedure
verification will depend on the type and complexity of the procedure. The three components of the Universal
Protocol are not necessarily presented in chronological order (although the preprocedure verification and site
marking precede the final verification in the time-out). Preprocedure verification, site marking, and the time-
out procedures should be as consistent as possible throughout the hospital.

Note: Site marking is not required when the individual doing the procedure is continuously with the patient
from the time of the decision to do the procedure through to the performance of the procedure.

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UP.01.01.01

Conduct a preprocedure verification process.

–Rationale for UP.01.01.01–

Hospitals should always make sure that any procedure is what the patient needs and is performed on the
right person. The frequency and scope of the verification process will depend on the type and complexity of
the procedure.

The preprocedure verification is an ongoing process of information gathering and confirmation. The purpose
of the preprocedure verification process is to make sure that all relevant documents and related information
or equipment are as follows:
– Available prior to the start of the procedure
– Correctly identified, labeled, and matched to the patient’s identifiers
– Reviewed and are consistent with the patient’s expectations and with the team’s understanding of the
intended patient, procedure, and site

Preprocedure verification may occur at more than one time and place before the procedure. It is up to the
hospital to decide when this information is collected and by which team member, but it is best to do it when
the patient can be involved. Possibilities include the following:
– When the procedure is scheduled
– At the time of preadmission testing and assessment
– At the time of admission or entry into the facility for a procedure
– Before the patient leaves the preprocedure area or enters the procedure room

Missing information or discrepancies are addressed before starting the procedure.

Element(s) of Performance for UP.01.01.01

1. Implement a preprocedure process to verify the correct procedure, for the correct patient, at the
correct site.
Note: The patient is involved in the verification process when possible.

2. Identify the items that must be available for the procedure and use a standardized list to verify their
availability. At a minimum, these items include the following:
– Relevant documentation (for example, history and physical, signed procedure consent form, nursing
assessment, and preanesthesia assessment)
– Labeled diagnostic and radiology test results (for example, radiology images and scans, or pathology
and biopsy reports) that are properly displayed
– Any required blood products, implants, devices, and/or special equipment for the procedure
Note: The expectation of this element of performance is that the standardized list is available and is
used consistently during the preprocedure verification. It is not necessary to document that the
standardized list was used for each patient.

3. Match the items that are to be available in the procedure area to the patient.

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Introduction to

UP.01.02.01

Wrong-site surgery should never happen, yet it is an ongoing problem in health care that
compromises patient safety. Marking the procedure site is one way to protect patients; patient
safety is enhanced when a consistent marking process is used throughout the hospital. Site
marking is done to prevent errors when there is more than one possible location for a procedure.
Examples include different limbs, fingers and toes, lesions, level of the spine, and organs. In cases
where bilateral structures are removed (such as tonsils or ovaries) the site does not need to be
marked.

Responsibility for marking the procedure site is a hotly debated topic. One position is that since the
licensed independent practitioner is accountable for the procedure, he or she should mark the site.
Another position is that other individuals should be able to mark the site in the interests of work flow
and efficiency.

There is no evidence that patient safety is affected by the job function of the individual who marks
the site. The incidence of wrong-site surgery is low enough that it is unlikely that valid data on this
subject will ever be available. Furthermore, there is no clear consensus in the field on who should
mark the site. Rather than remaining silent on the subject of site marking, The Joint Commission
sought a solution that supports the purpose of the site mark. The mark is a communication tool
about the patient for members of the team. Therefore, the individual who knows the most about the
patient should mark the site. In most cases, that will be the person performing the procedure.

Recognizing the complexities of the work processes supporting invasive procedures, The Joint
Commission believes that delegation of site marking to another individual is acceptable in limited
situations as long as the individual is familiar with the patient and involved in the procedure. These
individuals would include the following:
– Individuals who are permitted through a postgraduate education program to participate in the
procedure.
– A licensed individual who performs duties requiring collaborative or supervisory agreements with
a licensed independent practitioner. These individuals include advanced practice registered nurses
(APRNs) and physician assistants (PAs).

The licensed independent practitioner remains fully accountable for all aspects of the procedure
even when site marking is delegated.

UP.01.02.01

Mark the procedure site.

Element(s) of Performance for UP.01.02.01

1. Identify those procedures that require marking of the incision or insertion site. At a minimum, sites are
marked when there is more than one possible location for the procedure and when performing the
procedure in a different location would negatively affect quality or safety.
Note: For spinal procedures, in addition to preoperative skin marking of the general spinal region,
special intraoperative imaging techniques may be used for locating and marking the exact vertebral
level.

2. Mark the procedure site before the procedure is performed and, if possible, with the patient involved.

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3. The procedure site is marked by a licensed independent practitioner who is ultimately accountable for
the procedure and will be present when the procedure is performed. In limited circumstances, the
licensed independent practitioner may delegate site marking to an individual who is permitted by the
organization to participate in the procedure and has the following qualifications:
– An individual in a medical postgraduate education program who is being supervised by the licensed
independent practitioner performing the procedure; who is familiar with the patient; and who will be
present when the procedure is performed
– A licensed individual who performs duties requiring a collaborative agreement or supervisory
agreement with the licensed independent practitioner performing the procedure (that is, an advanced
practice registered nurse [APRN] or physician assistant [PA]); who is familiar with the patient; and who
will be present when the procedure is performed.
Note: The hospital’s leaders define the limited circumstances (if any) in which site marking may be
delegated to an individual meeting these qualifications.

4. The method of marking the site and the type of mark is unambiguous and is used consistently
throughout the hospital.
Note: The mark is made at or near the procedure site and is sufficiently permanent to be visible after
skin preparation and draping. Adhesive markers are not the sole means of marking the site.

5. A written, alternative process is in place for patients who refuse site marking or when it is technically or
anatomically impossible or impractical to mark the site (for example, mucosal surfaces or perineum).
Note: Examples of other situations that involve alternative processes include:
– Minimal access procedures treating a lateralized internal organ, whether percutaneous or through a
natural orifice
– Teeth
– Premature infants, for whom the mark may cause a permanent tattoo

UP.01.03.01

A time-out is performed before the procedure.

–Rationale for UP.01.03.01–

The purpose of the time-out is to conduct a final assessment that the correct patient, site, and procedure are
identified. This requirement focuses on those minimum features of the time-out. Some believe that it is
important to conduct the time-out before anesthesia for several reasons, including involvement of the patient.
A hospital may conduct the time-out before anesthesia or may add another time-out at that time. During a
time-out, activities are suspended to the extent possible so that team members can focus on active
confirmation of the patient, site, and procedure.

A designated member of the team initiates the time-out and it includes active communication among all
relevant members of the procedure team. The procedure is not started until all questions or concerns are
resolved. The time-out is most effective when it is conducted consistently across the hospital.

Element(s) of Performance for UP.01.03.01

1. Conduct a time-out immediately before starting the invasive procedure or making the incision.

2. The time-out has the following characteristics:
– It is standardized, as defined by the hospital.
– It is initiated by a designated member of the team.
– It involves the immediate members of the procedure team, including the individual performing the
procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other
active participants who will be participating in the procedure from the beginning.

3. When two or more procedures are being performed on the same patient, and the person performing
the procedure changes, perform a time-out before each procedure is initiated.

© 2020 The Joint Commission
Page 13 of 14

Report Generated by DSSM
Wednesday, Oct 28 2020
National Patient Safety Goals Effective
January 2021 for the Hospital Program

4. During the time-out, the team members agree, at a minimum, on the following:
– Correct patient identity
– The correct site
– The procedure to be done

5. Document the completion of the time-out.
Note: The hospital determines the amount and type of documentation.

© 2020 The Joint Commission
Page 14 of 14

Report Generated by DSSM
Wednesday, Oct 28 2020
National Patient Safety Goals Effective
January 2021 for the Hospital Program