Minnesota Hospital Association

Quality & Patient Safety

October 03, 2005

Minnesota Patient Safety Alert: Procedures performed outside of the operating room


MHA has reviewed data from hospitals that have agreed to share adverse health event reporting information and has noted a cluster of wrong body part events related to chest procedures.  Review of these events shows that these invasive procedures were performed outside the operating room (e.g. patient’s room, radiology department) and a “Time Out/Pause for the Cause” (pause and verification just prior to the incision or injection) was not conducted.   The Safest in America “Safe Site Protocol for Invasive and Surgical Procedures” (available at http://www.mnhospitals.org/inc/data/pdfs/SIA_ISCI_protocol.pdf) recommends pause and verification for all invasive procedures which should take place in the location where the procedure will be done.  This protocol is not limited to the operating room.


MHA recommends that all hospitals review their policies for invasive procedures performed outside of the operating room.  It is also recommended that hospitals have a system in place to check if pause and verification is taking place in these settings (in some instances it was thought that the process was taking place but there was confusion as to which settings the pause and verification process applied).

Some Minnesota hospitals are developing a process in which a pause and verification checklist is automatically printed with each informed consent document and are standardizing their protocols and forms across their organizations.