2 Surgical Safety and Verification

A coordinated safety process

Wrong-patient, wrong-procedure, and wrong-site surgery are prevented through several coordinated checks, not by relying on memory or a single person. The Universal Protocol centers on preprocedure verification, site marking, and a final time-out. If information conflicts or a required check is incomplete, pause and resolve the issue before proceeding.

Identify the patient

Use the facility's approved patient identifiers and compare them with the patient's identification band and relevant records. When possible, ask the patient to state identifying information rather than asking a yes-or-no question that suggests the answer. A room or bed number is not a patient identifier.

If the patient cannot confirm their identity or planned procedure, verification is still required. Follow the organization's process, using available authoritative records and team communication; do not omit verification or rely only on team members recognizing the patient.

Verify the procedure and site

Before the procedure, reconcile the schedule, consent, the patient's account when available, clinical documentation, and relevant images or test results. Missing or conflicting information must be addressed before proceeding.

For example, if the consent lists a left-side procedure but the schedule lists the right side, stop and resolve the discrepancy with the responsible clinicians. Neither the schedule, a skin mark, nor a majority of team members resolves conflicting information on its own.

Mark the site when indicated

Mark the correct site before the procedure when more than one location is possible and operating at the wrong location could harm the patient. Involve the patient when possible and follow the organization's approved process. When marking is not possible or appropriate, use the approved alternative process.

Site marking is one part of coordinated verification; it does not replace checking the patient and procedure during the time-out. If a site mark is not visible after preparation and draping, stop and re-establish the correct site using the organization's approved process before incision. Do not guess or proceed with unresolved uncertainty; repeat or complete required verification as directed by policy.

Conduct an active final time-out

Immediately before incision or an invasive procedure, the active team pauses and verbally confirms the correct patient, procedure, and site. Team members participate actively; silence is not confirmation. If a team member is silent or a stated site differs from the consent, stop and clarify the discrepancy. Do not begin until concerns are resolved.

When a second procedure is planned and a different practitioner will perform it, conduct another time-out before starting that procedure. Do not rely on the first time-out for both procedures.

Use checklist checks as complements

The WHO Surgical Safety Checklist also includes a sign-in before anesthesia and a sign-out before the patient leaves the operating room. These checks support team communication and complement local policy and the final time-out; they do not replace it.

Respond to uncertainty

Use this sequence when any required check is incomplete or information is uncertain:

1. Pause the procedure.

2. Identify the missing check or discrepancy.

3. Reconcile the information with the responsible clinicians and the organization's process, using available authoritative records and team communication when needed.

4. Complete or repeat required verification as directed by policy.

5. Proceed only when the concern is resolved.

Every team member should speak up about uncertainty. A nod in response to a suggested name, a silent time-out, an invisible site mark, or agreement from most of the team is not a basis for proceeding when verification remains unresolved.