Institute for Healthcare Improvement: Procedure Without Sedation: Procedural Pause Documentation Form

Virginia Mason Medical Center (VMMC) implemented a Procedural Pause protocol to prevent wrong site, wrong procedure, and wrong person surgery. A pause is to be performed and documented on all procedures in which a written Informed Consent was obtained from the patient.

The pause requires the entire medical team to agree on the patient’s identity and all of the required elements of the impending procedure by using verbal communication — no nods or hand signals — and consulting supporting documents, such as test results, if applicable. If any member of the team does not agree on the relevant information, the procedure does not go forward.

To ease the process, VMMC developed this optional documentation form in which the procedural pause elements are listed in large black letters. The nurse manager on each case can fill out the form, showing that all the steps in the procedural pause have been completed, or the physician can dictate into the procedural record that the procedural pause was completed.

Background

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."