Quality and Safety
Correct Patient/Patient Identification in NSW

FAQ

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Toolkits

How can I get more copies of the toolkit posters for radiation therapy, radiology, nuclear medicine and oral health?: Details for ordering more copies of the posters are shown at http://www.health.nsw.gov.au/quality/correct/safetykit.html.
Is there a revised poster for surgery?: We are currently developing a poster for surgical areas that matches the revised policy.
Are there trolley slips available for nuclear medicine, like the radiology ones?: We do not have slips available for Nuclear Medicine and at this stage have no plans to develop them but some Area Health Services are considering developing one for their own internal purposes. If an Area does develop one we will seek to put a copy on our website for other areas to use as a reference.
How can I get more copies of the radiology trolley slip “cheque books”?: Details for ordering more copies of the radiology trolley slip cheque books are shown at http://www.health.nsw.gov.au/quality/correct/safetykit.html.
When will the next audits be performed?: Following the initial audit in April 2008, it is planned that audits will be conducted quarterly in the months August, November, February and May.
Does the audit just look at surgery or are the other areas (radiology, nuclear medicine, radiotherapy and oral health) also included?: We are only auditing surgery at present but there is an intention to expand the auditing to include other areas in the future.
Is the audit just looking at the Time Out process?: At present we are just looking at time out in the audit and we haven't considered auditing other parts of the process. This is due to it being a bit easier to do as it can be done based on the documentation at time out and because it covers all of the checks that need to happen prior to the procedure, and the new policy inclusions.
If the facility is not using a checklist then do we audit the notes for evidence of the checks being undertaken or is it an observational audit?: It is a documentation audit, looking for evidence that the checks have been performed either by examining checklists or other documentation
How does the data submission process work?: The process is that hospitals do their individual audits, send the data to the Area Health Service office and the Area team will need to complete the web-based form to submit the final results for each hospital. This will mean that (a) it won't matter that some sites cannot access the internet and (b) data can be reviewed at the AHS before submission to the Department.
The time frames for reporting following the audit are very short if they are auditing records as it will involve a lot of chasing records on the day, and afterwards, as most checklists go with the medical record which will be going to a ward with the patient or back to medical records the next day or that day.
To address this issue some sites are choosing to do the audit in recovery, where the patient and their documentation are readily available.
Is compliance with the policy mandatory?: Yes. All public hospitals and health facilities are required to comply with the Correct Patient, Correct Procedure, Correct Site Model Policy. All licensed private facilities are strongly recommended to refer to the policy in developing similar policies suitable to their settings.
What is the difference between the words "must" and "should" in the Model Policy?: The word "must" refers to mandatory requirements that must be done as stated in the Policy. The word "should" refers to preferred approaches to be undertaken wherever possible and allows a degree of flexibility to meet the characteristics of individual health settings.
What procedures fall within the scope of the policy?: For the purpose of this policy, the term “procedure” includes all surgical, dental surgical, radiological, radiation therapy, radionuclide therapy, chemotherapy or endoscopic manoeuvres that potentially expose a patient to harm or risk. It does not include ultrasound investigations, placement of a peripheral venous cannula, or taking of blood.
How often must the pre-procedure verification process be conducted?: It is essential that the patient's identity is matched with relevant documentation at EVERY stage of the journey through a hospital or health facility. This includes:

when the procedure is scheduled

at admission into the facility (if applicable)

any time the responsibility for care of the patient is transferred

during preparation of the patient for their procedure

on entry to the procedure suite or treatment area

just before entering the room in which the procedure will occur or as soon as practicable after entering the procedural room but prior to anaesthetising the patient.
When must the body site be marked?: Site marking is essential when there is the potential for error involving left/right distinction (such as left or right leg, kidney etc.) multiple body parts (such as fingers and toes) or multiple levels in the body part (such as the spine).
Site marking is not required (although it can be used) in the following circumstances:

to avoid confusion, (for example, if a procedure requires a regional anaesthetic, then only the procedure site should be marked)
for radiology procedures or investigations where marking the site could add to the ambiguity of subsequent procedures
for single organ cases (for example cardiac surgery, caesarean section)
if the site is obvious (for example open trauma wound, large tumour)
for interventional cases where the catheter/instrument site is not predetermined (for example, cardiac catheterisation, epidural/spinal analgesia/anaesthesia)
where the site of surgical entry is unambiguous (for example, midline incisions, cystoscopies, laparoscopies)
when intra-procedure imaging for localisation, (for example, radiological, MRI, stereotaxis, ultrasound, radiation detection will be used)
where the procedure site cannot be marked (eg. teeth). In these cases, relevant radiographs or other scans must, if possible, be marked to indicate the site. Where this is not possible, a diagram clearly indicating the site and side must be prepared and entered into the patient’s medical record
for premature infants, and some oral and maxillofacial surgery, where marking may cause permanent tattoos
for multiple fractions of radiotherapy, where markings usually need only be done before the first fraction and only reapplied as necessary and where markings are applied to the immobilisation device rather than on the patient skin
where the patient refuses marking. Such refusal must be documented in the patient’s medical record
in a life-threatening emergency where the patient enters the procedure room directly. This must be documented in the patient’s medical record.
If the site does not need to be marked do other provisions of the model policy still apply?: Yes. ANY operative or other invasive procedure that exposes patients to more than minimal risk, including procedures done in settings outside operating rooms, require the preoperative verification process and "time out" procedures to be applied.
Certain routine "minor" procedures such as ultrasound investigations, venipuncture, peripheral IV line placement, insertion of a NG tube, or Foley catheter insertion do not fall into this category.
How should the site of procedures on hands, feet or limbs be recorded in the documentation?: Fingers are best described in hospital records as: thumb, index, middle, ring and little. This avoids confusion regardless if the palm is facing up or down. Toes are best described as hallux, second, third, fourth and fifth. Left/right distinctions must be written in full to avoid ambiguity.
Should the site be marked with an X, the word "yes", or the surgeon's initials?: Initials should not be used in marking. The word "yes", a tick or an arrow indicating the intended site of incision are preferred symbols. The choice of symbol is left to individual organisations, however, the mark must be unambiguous and the agreed symbol consistent throughout the organisation. The use of "X" is discouraged because it creates ambiguity. "X" could mean "operate here" or "do not operate here". Hospitals and health facilities should consider aligning site marking procedures throughout a geographic area, since surgeons often work across facilities.
What kind of marker should be used?: The marker should be sufficiently permanent so that it will not wash off when the site is prepped. The mark should be visible after the patient is prepped and draped unless it is technically or anatomically impractical. In these situations a supplementary method should be used, such as a unique wrist band indicating left/right distinctions.
Does marking increase infection risk?: There is no evidence in the literature that marking creates an increased infection risk although better practice in infection control suggests the single use of sterile marker pens. The marker should be discarded after use if applied to broken skin or to a patient known to have a communicable skin disease.
How do you mark the skin of patients with very dark skin?: A dark blue or black marker will provide a discernible mark on any patient, regardless of skin colour. If the mark is not clearly visible, and the staff or patient are concerned, a special-purpose wristband can be also be used.
In left/right body part procedures is it acceptable to mark the body part not requiring a procedure with a "No"?: Only the intended site can be marked. Marking the non-operative site is explicitly prohibited unless it is to alert the clinician to an important aspect of care, such as using a particular access vein due to a prior surgical procedure.
Who should mark the site?: The site must be marked by the person performing the procedure or his/her delegate, except in ocular surgery under prescribed circumstances. The person performing the procedure is defined as the surgeon/proceduralist. The delegate is defined as someone who is performing, or assisting, the surgery or procedure. In some cases this delegate may be the anaesthetist as long as he/she is fully briefed.
For intra-ocular surgery where pre-operative mydriatic drops have been ordered, the correct site can be marked by a registered nurse, and the marking checked by a second registered nurse before the drops are
given, in conjunction with the proper confirmation of the patient’s identity, checking of the consent, and verbal confirmation by the patient or “person responsible” of the side to have surgery. The mark must be subsequently checked as the correct side for the surgery with the proper confirmation of the patient’s identity, checking of the consent, and verbal confirmation by the patient or "person responsible", before the anaesthetic (regional or otherwise) is given and during the “Time out”. These checks must involve the anaesthetist and operating surgeon, respectively.
Should the patient mark the site?: No. The patient should be involved in the process of identifying the site but it is not recommended that he/she marks the site.
When should the site be marked?: Whenever possible, marking must take place with the patient involved, awake and fully aware. Unless there is an emergency this should occur before the patient enters the procedure room. Patients compromised by disease or sedation can still participate. It is up to the clinician to assess the patient's level of ability to do so.
What if the patient cannot participate in site marking?: The site marking process is handled in the same way as the informed consent process eg: if the patient is comatose, mentally incompetent, has language difficulties or is a child. In these cases (and if appropriate) the person with authority to provide informed consent would also participate in marking the site.
What if the patient refuses site marking?: It is the responsibility of organisations to explain why site marking is appropriate and desirable, and the implications of refusal so that patients can make an informed decision. However, the patient always has the right to refuse.
Such situations should be handled the same way as for any other refusal by a patient offered care, treatment or services. A refusal to have site marking should not result in the procedure being cancelled; however, the refusal must be documented in the patient's medical record.
What is the recommended procedure for marking spinal surgery?: Intraoperative and external marking is advised as there have been cases where a lumber procedure was started on a patient intended for a cervical procedure and vice versa. The exact interspace(s) to be operated on should be marked precisely using the standard intraoperative radiographic marking technique.
The left/right, anterior/posterior position and the level must then be marked on the skin using the agreed marking symbols (see above).
How is the skin marked when gaining access to an internal left/right body part through a mid-line incision or natural opening such as the mouth nose or anus?: Hospitals and health facilities must establish recognised symbols for marking the skin at or near the proposed incision or insertion site to indicate the correct side for the procedure.
Do you need to mark the site for laparoscopic procedures?: Where the laparoscopic procedure is being performed on paired organs such as kidneys, the site should be marked to indicate the intended kidney, even though the insertion site of insertion is midline.
How are dental procedures marked?: There is no practical way of marking teeth. The proceduralist must review dental records, the patient history, laboratory findings, appropriate charts and x-rays. The tooth (or teeth) should be clearly marked on the relevant x-rays or other scans. The two person rule applies when labelling imaging data to ensure proper orientation and accuracy.
In the absence of radiographs or other scans a diagram should be prepared that clearly indicates the site(s) involved in the procedure and entered into the patient's medical record. As in all other procedures "time out" should be conducted at the time of extraction to verify the correct patient, correct site and procedure to be undertaken.
How are ophthalmology procedures marked?: Eye preparation, such as pupil dilation, often occurs some time before a procedure begins and often is conducted by someone other than the proceduralist. Therefore, as in all other procedures, site marking should take place with the patient awake, alert and involved, and prior to admittance to the procedure room.
The mark should be unambiguous and located near the eye to be operated upon (see above).
For intraocular surgery where pre-operative mydriatic drops have been ordered, the correct site can be marked by a registered nurse and the marking checked by a second registered nurse before the drops are given. These checks are in conjunction with the proper confirmation of the patient's identify, checking of consent, and verbal confirmation of the patient or "person responsible" of the side to have surgery.
Must the site be marked if there is an obvious wound or lesion?: No. Marking is not required if the wound or lesion is at the intended procedure site. However, if there are multiple wounds or lesions and only some of them are to be treated, the decision about which are to be treated is determined at some time prior to the procedure itself. Therefore, the sites to be treated should be marked as soon as possible after the decision is made.
Is it necessary to mark the site of a bedside procedure?: If the clinician remains with the patient from the time a decision is made to conduct a procedure, through the consent process and up until the procedure begins, then site marking is not required, but this is at the discretion of the clinician. If the clinician leaves the patient for any amount of time the site should then be marked.
Should sites be marked in an emergency?: In most emergency situations the clinician performing the procedure is continually with the patient from the moment the decision is made and through the actual procedure itself. Marking the site is not necessary in these circumstances.
However, "time out" to verify the correct patient, procedure and site is appropriate unless the time taken adds more risk than benefit in the situation.
What if the site to be marked is embarrassing?: You must mark the site or very near to it. A surprising number of the incorrect surgeries in Veteran Affairs facilities in the USA over the last three years have been to sites in the groin, genitals, or somewhere on the buttocks. If the patient requests that the site not be marked, then a special-purpose wristband can be used instead. However the reason for using a special purpose wristband should not be because of the clinician's reluctance to mark the site.
What happens to site marks when a patient requires multiple surgeries during a hospital stay?: When there are multiple procedures to be carried out in a specific sequence, systems should be put in place to ensure the clinically indicated order is being followed and that the site of the intended procedure for that day and time is correctly marked.
The site mark should be removed at the end of the procedure to ensure it is not confused with the next operation, unless the procedure is to continue on the same site.
Is Time Out required for a general anaesthetic?: The policy does not require "Time Out" per se but there is a requirement under 1.5 for "Verification of the correct patient, correct procedure and correct site... prior to the competent patient receiving medication that could affect their cognitive function."
What antibiotics are covered by the antibiotic prophylaxis question? Does it include antibiotics given after the surgery?: The question around antibiotic prophylaxis is to determine whether the patient has had an assessment for their need of antibiotic prophylaxis, regardless of what their prophylactic requirements may be. We have received feedback that some antibiotic prophylaxis occurs post-surgery so the sub-question on the Time Out Checklist in the Policy "If yes, has it been given?" is not appropriate in such circumstances.
What is meant by special pre-operative medications?: There is no clear definition of the special pre-op medications and this is proving very difficult to interpret because there is such a wide range of medications used in different types of surgery. The intention was to check that patients had received any required pre-operative medication, to avoid situations where there are complications following the surgery because the appropriate pre-operative medications were not administered/taken. For example, for some operations the anaesthetist will request particular medications be given prior to surgery, despite the patient being nil by mouth.
Should the patient be anaesthetised before "time out" is conducted?: "Time out" is a final confirmation to match the (now identified) patient, procedure, correct site and side with imaging data and the availability of the correct implant or other equipment. As such it should occur immediately before the actual procedure begins.
Some health professionals have suggested that the patient should be awake and included during this process, as this input may prevent an unnecessary anaesthetic and its associated risks. However this operative pause should be viewed in the context of a chain of verification steps in which the patient has been actively involved in confirming his/her identity.
Who should participate in the "time out" process?: "Time out" must involve all members of the procedure team. Any member with doubts about the correct patient, procedure, site, implants or other equipment must speak up.
Is "time out" required if an individual conducts the procedure?: Yes. The steps outlined in the Model Policy for "time out" still apply in the absence of a team. Individual clinicians must pause to confirm patient details, the site, procedure and equipment. This essential process allows clinicians to collect themselves before commencing a procedure.
What is meant by active communication?: "Active communication" means that the absence of a response from a team member should not be interpreted as agreement to a question. This does not mean team members are required to repeat confirming details regarding patient identity, the procedure and so on. It is sufficient to signal agreement with a brief verbal acknowledgement, nod or other gesture. However the response must be seen and/or heard.
How are images such as x-rays checked as part of the "time out" process?: The patient's identity, the site of the procedure and the date of the image, as they all relate to the procedure, should match. Ensure that the image is for the correct side of the body, oriented correctly and labelled with the patient's name and date of birth.
What is involved in checking correct implants and prostheses?: It is highly recommended that each facility have a process for checking such items prior to preparing surgical lists. "Time out" is a final verification that this checking has occurred. The proceduralist and the assisting nursing staff must confirm that any correct prostheses (including biological implants) and/or any specialised equipment are in the procedure room and that they are the correct type and size.
What is meant by a dispute resolution policy?: Such a policy provides guidance in situations where there is a failure to communicate critical information, where clinicians disagree or where there is missing information, implants and equipment. It is not to be confused with an industrial relations dispute policy that handles staff grievances. Each health facility must have a policy (which may be part of the correct patient, procedure, site policy) to address these situations in a way that does not compromise patient safety and quality of care.
The policy should address questions about resolving disputes and in what situations a procedure should be cancelled completely. The policy would also identify who is responsible for making such decisions.
It is important to note that where there are discrepancies in information or disagreements in verification, the procedure should be delayed until the issues are resolved. The decision to proceed should be in keeping with the urgency of the procedure. Justification for proceeding in the presence of discrepancies must be documented in the patient's medical record.
In extreme emergencies the most senior member of the team is responsible for patient care and should decide.