Unit 4: Administrative Operations
Administrative Operations

Section 1. Policies and Procedures

Time-Out Policy

A time out is the last in a series of steps established in 2003 as part of the Joint Commission's Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. Every clinic accredited by the Joint Commission is required to have a time-out policy. Even if your clinic is not accredited, a time-out policy should be considered to help prevent the wrong teeth from being treated or extracted. 

The time-out procedures specified by the Joint Commission include the following components:

  • Pre-procedure verification of the patient, the procedure, and the site of the procedure are completed (e.g., “Jane Doe, simple extraction, necrotic tooth #6”; “John Doe, DO amalgam, caries into dentin tooth #30”).
  • The time out is initiated by a designated member of the treatment team, usually the dentist.
  • The time out is conducted in a fail-safe mode, meaning that the procedure is not initiated until all questions or concerns have been resolved.
    • The time out involves interactive verbal communication with the patient, if possible, and all team members. Any team member is able to express concerns about the procedure verification.
  • The time out includes a process for reconciling differences in responses among team members.
  • The completed components of the time out are clearly documented in the patient’s records. According to the Joint Commission, "while it is expected that all the components of time-out are performed as specified, it is not necessary to individually document each of them. Therefore, one checkbox or a brief note regarding the successful completion of the time-out, located in a consistent location in the patient record, is adequate documentation as long as the full content of the time-out is specified elsewhere (policy, procedure, etc.)."

While part of the Joint Commission’s Universal Protocol includes surgical site marking, the Joint Commission recognizes that there does not appear to be a practical or reliable method by which to mark the intended for extraction or surgery. Therefore, dental procedures are considered exempt from the site-marking requirement. Rather, the Joint Commission recommends the following:

  • Review the dental record including the medical history, laboratory findings, appropriate charts, and dental radiographs. Indicate the tooth number(s), or mark the tooth site or surgical site on the odontogram or radiograph to be included as part of the patient record.
  • Ensure that radiographs are properly oriented, and visually confirm that the correct teeth or tissues have been charted.
  • Conduct a time out to verify patient, tooth, and procedure, with assistant present at the time of the extraction.