Patient Identification & Verification

Patient safety begins before the patient enters the operating room. The surgical technologist is a vital member of the team responsible for verifying that the right patient receives the right procedure on the right site.

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The Universal Protocol (Joint Commission)

The Universal Protocol is a set of mandatory safety steps designed to prevent wrong-patient, wrong-site, and wrong-procedure events. It consists of three components:

1. Pre-Procedure Verification

This is an ongoing process that begins before the patient arrives in the OR:

• Verify patient identity using at least two unique identifiers (e.g., full name and date of birth)
• Confirm the intended procedure matches the consent form, history & physical, and OR schedule
• Verify all required documents, labs, imaging, and implants are available and correctly labeled
• The patient's medical record, wristband, and verbal confirmation should all match

2. Surgical Site Marking

• The surgeon or proceduralist marks the operative site before the patient enters the OR
• Site marking is required for procedures involving laterality (left/right), multiple structures (e.g., fingers, toes), or multiple levels (e.g., spinal procedures)
• The mark must be made with a permanent marker and must be visible after prepping and draping
• The patient should be involved in the marking process whenever possible

3. Time Out

The Time Out is performed immediately before the procedure begins:

• The entire surgical team must participate (surgeon, anesthesiologist, surgical technologist, circulating nurse)
• All other activities must stop during the Time Out
• The team verbally confirms:
  • Correct patient identity
  • Correct procedure
  • Correct site and laterality
  • Patient positioning
  • Availability of implants, special equipment, or devices
  • Antibiotic prophylaxis administered (if applicable)
  • Relevant imaging displayed

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Informed Consent

Informed consent is a legal and ethical requirement for any surgical procedure:

Important rules about surgical consent:

• Consent must be obtained before any sedation or anesthesia
• It is the surgeon's responsibility to explain the procedure, but the circulating nurse may witness the signature
• The surgical technologist should verify that the signed consent matches the scheduled procedure
• Minors require consent from a parent or legal guardian
• In a life-threatening emergency where the patient cannot consent and no surrogate is available, implied consent may apply