An excerpt from the AAAASF Standards and Checklist for accreditation of ambulatory surgery facilities:

200 OPERATING ROOM POLICY, ENVIRONMENT AND PROCEDURES 10 Policy

210-010 B, C-M, C
A policy for a ‘surgical pause' or a ‘time out' protocol is in place and practiced prior to every surgical procedure.

This protocol should include -

Pre-operative verification process to include medical records, imaging studies, any implants identified and reviewed by the operating room team. Missing information or discrepancies must be addressed at this time.

Marking the operative site -

Surgical procedures calling for right/left distinction; multiple structures (breasts, eyes, fingers, toes, etc.) must be marked while the patient is awake and aware, if possible. The person performing the surgery should do the site marking. Site must be marked so that the mark will be visible after the patient has been prepped and draped. A procedure must be in place for patients who refuse site marking.

‘Time Out' immediately before starting the surgical procedure -

Conduct a final verification by at least two (2) members of the surgical team confirming the correct patient, surgery, site marking(s) and, as applicable, implants and special equipment or requirements. As a ‘fail-safe' measure, the surgical procedure is not started until any and all questions or concerns are resolved.

Procedures done in non-operating room settings must include site marking for any procedure that involves laterality, or multiple structures.