Virginia Mason Medical Center (VMMC) implemented a Procedural Pause protocol to prevent wrong site, wrong procedure, and wrong person surgery. To gauge compliance with the new protocol, the medical center conducts monthly audits of departments every time they perform ten procedures or more.

A pause is to be performed and documented on all procedures in which a written Informed Consent was obtained from the patient.

The protocol’s three major elements include: 

1. Initial verification of the intended patient, procedure, and site of the procedure
2. Marking the intended site with a sterile pen, where applicable
3. A final “time-out” immediately before beginning the procedure in which medical team members actively verify each element listed above.

During this process, caregivers also make sure that the patient is in the correct position and that all relevant medical records and documents related to the procedure are on hand.

In July 2004 the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) required that providers follow a Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.

Under the JCAHO protocol, even an accidentally mismarked site is almost certain to be noticed and properly identified during the required “time-out” — which Virginia Mason Medical Center calls a “procedural pause” — immediately before the procedure begins.

Read the related story about VMMC's implementation of the protocol, "Pausing for Safety."

Download the tool.

1. Each month select a minimum of either 10 patient charts, or observe 10 procedures, for patients from whom a written Informed Consent was obtained. 
2. For each patient chart, indicate on the Audit Tool whether or not all required elements of the Procedural Pause (see the "Elements of a Pause" section on the Audit Tool) were performed and documented for the patient by indicating "Yes" or "No." [NOTE: If some but not all of the elements of the Procedural Pause were performed and documented, then answer "No" on the Audit Tool.] 
3. For each "No" response, provide an explanation as to why the procedure was not followed and any just in time teaching that was done.
4. To calculate the compliance rate with the new protocol standard, count the number of "Yes" responses for that month and divide by the total number of patient charts/procedures reviewed or observed.

This tool may be used in conjunction with the Procedure Without Sedation: Procedural Pause Documentation Form.