Implementing the SAFE SITE Bundle

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Implementing theSAFE SITE Bundle By Dana M.
Langness, RN, BSN, MA Senior Director
Perioperative Services Regions Hospital, St. Paul
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Implementing the SITE Bundle

• S Sign site with initials
• I Informed Consent Verification
• T Time-Out
• E Effective Communication

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S - Sign site with initials
ACTION Mark the procedure site.

• The facility requires, AND has a designated place
  to document, that the provider performing the
  procedure marks the procedure site with their
  initials.
• Verifies patient identity, correct site and side
• Mark visible when patient positioned and draped
• Exceptions to marking
• Single organ
• Teeth
• Premature infant
• Intervention procedures where insertion site not
  predetermined
• Procedure through orifice not associated with
  laterality
• Provider performing procedure is in continuous
  physical presence from arrival for procedure to
  conclusion of procedure
• Site sensitive areas may be marked above or
  lateral to the site
• Patient refusal must be documented

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S - Sign site with initials
ACTION Mark the procedure site (continued).

• The facility requires that an indelible
  (permanent) non-toxic marker is used to mark the
  procedure site.

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S - Sign site with initials
ACTION Multiple sites are labeled in medical
record and are numbered accordingly.

• The facility requires, AND has a designated place
  to document, that multiple procedure sites are
  labeled in the medical record and are numbered
  accordingly on the procedure sites.

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I - Informed Consent Verification
ACTION Verify.

• Informed consent with patients medical record.
• Informed consent indicates laterality, including
  internal laterality
• Patient identification with two indicators.
• Procedure to be performed.
• Procedure site and laterality and/or level

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I - Informed Consent Verification
ACTION Verify.

• If site is not signed or verification has not
  been completed or reconciled
• The patient is not moved into the OR or procedure
  area (if applicable for the invasive procedure)
• Verification must be completed and/or reconciled
• If unable to complete or reconcile, procedure
  cancelled/rescheduled
• For Anesthesia Procedures
• Anesthesia verification of correct site and side
  using
• Informed consent with patients medical record.
• Discussion with patient/legal guardian.

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T - Time-Out
ACTION Active, verbal participation in
Time-out by the Full Team.

• In the OR, the surgeon is responsible for
  calling for the time-out prior to starting
  the procedure.
• All team members are required to stop other
  activities and pause for the duration of the
  time-out.
• Each member of the surgical/procedure team is
  required to give an independent, verbal
  confirmation.
• A reconciliation process is in place for any
  discrepancies noted during the time out.
• An additional time-out is performed if there is a
  disruption during the time-out.
• A briefing (hand-off) is in place for replacement
  staff if staff changes occur during the
  procedure.
• Anesthesia Time-out with one other member of
  care team before a block is administered.

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T - Time-Out
ACTION Institute a Hard Stop if a time-out is
not performed.

• Level II Hard Stop
• Further work to begin the procedure is stopped by
  all members of the team.
• Any member calling for a hard stop is supported.

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T - Time-Out
ACTION Final visual check for site marking.

• The person performing the procedure conducts a
  final visual check for the site mark immediately
  proceeding the procedure after patient has been
  draped and positioned.

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E - Effective Communication
ACTION Team Communication.

• Pre-Operative Review
• Relevant images
• Implants or special equipment
• Special patient issues
• Patient positioning and other pertinent
  information
• Intra-operative implants
• Implant specification/type/expiration date
• Size
• Laterality
• Intra-operative internal laterality
• Verify target site
• Confirm procedure to be performed

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E - Effective Communication
ACTION Team Communication (continued).

• Intra-operative Spine/other level procedures
• Procedure site has been marked including anterior
  or posterior, approximate level and laterality
• Pre- and intra-operative imaging present
• Time-out verification process
• Verification of level using opaque markers with
  specific bony landmarks and compared with
  pre-operative imaging
• Intra-operative pause after midline entry
  indicating laterality and level

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E - Effective Communication
ACTION Team Communication (continued).

• Designate the person (role) responsible for
  ensuring the pre-operative safe site processes
  are completed for each patient.

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The world stands out on either side No wider than
the heart is wide Above the world is stretched
the sky, No higher than the soul is high. The
heart can push the sea and land Farther away on
either hand The soul can split the sky in
two, And let the face of God shine through.
- Edna St. Vincent Millay
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Questions?