Ensuring correct treatment and surgery on the correct patient and correct site

The 5-step verification process outlined in OD 0004/06 Correct Patient, Correct Procedure, Correct Site Policy and Guidelines for WA Health Services (external site) must be used in all of the below specialties:

  • surgical
  • anaesthetic
  • medical
  • radiology
  • oncology
  • endoscopy
  • telemedicine.

The 5-step process involves:

Step 1 – Ensure that valid consent has been obtained from the patient.

Step 2 – Confirm the patient’s identity.

Step 3 – Mark the site of the surgery or invasive procedure.

Step 4 – Ensure the correct and appropriate documents and diagnostic images are available.

Step 5 – Take a final ‘team time-out’ in the operating theatre, treatment or examination area.

Step 1 – Obtaining valid consent

Informed consent is a patient’s voluntary agreement for a doctor or health practitioner to provide treatment, including any medical or surgical management, care, therapy, test or procedure.

A health practitioner has 3 obligations to fulfil. They must:

  1. inform the patient of the nature of the proposed treatment and disclose any material risks involved in it
  2. obtain the patient’s consent for the treatment or procedures
  3. document that consent process in the patient’s medical record or on a consent form.

As a matter of policy, no surgical operation, medical, anaesthetic, radiology or oncology procedures may be performed without the valid, informed consent of the patient, if the patient is a competent adult.

The process and requirements for obtaining a patient’s consent may vary depending on the competency and age of the patient.

The WA Department of Health issued OD 0324/11 Consent to Treatment Policy for the Western Australian Health System 2011 (external site) to assist health professional meet their legal obligations in seeking and obtaining consent.

Step 2 – Confirming the patient’s identity

When preparing the patient for their treatment or procedure, a ‘team time-out’ should be taken in the patient’s room or waiting room, if the patient is an outpatient.

Prior to the patient receiving any medication, a member of the clinical team should initiate the team time-out to confirm the following:

  • patient’s full name, date of birth and UMR number
  • type of or treatment or procedure
  • reason for the treatment or procedure
  • treatment/procedure site (including correct side and laterality).

This information must be cross-checked against the information on the patient’s identification band, medical record and consent form.

A member of the clinical team should record the completion of this step in the patient’s medical record and sign the pre-operative verification checklist.

Step 3 – Marking the side and site of the surgery or procedure

The person performing the surgical or interventional procedure or a delegated senior member of the clinical team must mark the side and site of the procedure/surgery on the patient’s skin with a water resistant marker pen before the administration of the pre-operative medication.

Except in an emergency, marking must take place when the patient is awake and before the patient enters the procedure room.

The intended site of incision or site of insertion must be unambiguously marked. All cases involving laterality, multiple structures (for example fingers, toes or lesions) or levels (for example, the spine) must be clearly marked. Do not mark non-procedure sites.

Once the marking has been completed the clinical team should record the completion of this step in the patient’s medical record and sign the pre-operative verification checklist.

Where the patient refuses marking, this must be documented in the patient’s medical records and alternative strategies employed to prevent the procedure being performed on the wrong site.

Step 4 – Imaging data

Where imaging data is used during the marking process, 2 or more members of the clinical team must confirm that the images are properly labelled and are for the correct patient.

Step 5 - Taking a ‘team time-out’

Before the surgery or procedure starts, members of the clinical team must take a short ‘team time-out’ to verify for the last time the presence of the correct patient, the correct type of procedure to be performed and that the side and site of the procedure has been correctly marked.

Members of the clinical team must independently verify the following details:

  • the presence of the correct patient
  • the correct type of procedure to be performed
  • that the correct procedure site has been marked
  • availability of any correct prostheses and/or any specialised equipment or requirements.

A member of the team should be delegated to document the completion of the final ‘team time-out’ and sign the pre-operative verification checklist dem­onstrating the completion of this process.

References

Australian Council for Safety and Quality in Health Care (2004). Patient brochure: Understanding your surgery. See Australian Commission on Safety and Quality in Health Care (external site).

Joint Commission on Accreditation of Health Care Organizations (external site). 2005. Speak Up: Help Prevent Errors in Your Care: For Surgical Patients.

Department of Health (2006). Correct Patient, Correct Site and Correct Procedure Policy and Guidelines for WA Health Services.

More information

Quality Improvement and Change Management Unit
Address: 189 Royal Street, East Perth
Phone: 9222 4080
Email: qicm@health.wa.gov.au


Produced by

Quality Improvement and Change Management Unit