Transport of patients on Transmission based precautions: Limiting the
movement and transport of patients on transmission based precautions and ensuring
that such patients leave their rooms only for essential purposes reduces the opportunity
for transmission of microorganisms.
Signage: Signs will be placed when transmission based precautions are in place. The Contact,
Droplet and Airborne signs will be used as indicated to inform all HCP taking care of the patient
of the need for precautions. Patient, family and visitor education regarding precautions and the
proper use of personal protective equipment will be provided.
UNIVERSAL PROTOCOL Performing wrong site, wrong procedure, and wrong person must be prevented. Active
involvement and effective communication among all members of the surgical team is vital for
success. To the extent possible, the patient (or legally designated representative) should be
involved in the process. Consistent implementation of a standardized approach is most
effective. A requirement for site marking should focus on cases involving right/left distinction,
multiple structures (finger, toes) or levels (spine).
The universal protocol should be applicable or adaptable to all operative and other invasive
procedures that expose patients to harm, including procedures done in settings other than the
operating room.
Pre-operative verification process:
Ensuring that all relevant documentation and studies are available prior to the start of
the procedure and that they have been reviewed and are consistent with each other and
with the patient’s expectations and with the team’s understanding of the intended
patient, procedure, site and as applicable, any implants. Missing information or
discrepancies must be addressed before starting the procedure.
Marking the operative site. Identify unambiguously the intended site of incision or
insertion. The intended site must be marked so that the mark will be visible after the
patient has been prepped and draped.
