Chapter 4. Clinical Operations

Policy and Procedure Manual

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.

At least one dental program in an IHS hospital has applied the time-out policy to all of its invasive procedures (e.g., restorative procedures), not just extractions. As the chief dentist of this program has stated, "we can still prep the wrong tooth for an amalgam, which is not as serious as removing the wrong tooth, but is still bad. If we institutionalize time-outs for everything, then one does not need to stop and think, "Does this procedure require a time out?."

The time-out procedure specified by the Joint Commission includes the following components:

  • Pre-procedure verification of the patient, the procedure, and the site of the procedure (e.g., Jane Doe, extraction, tooth #6: or John Doe, DO amalgam, 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
    • It involves interactive verbal communication among all team members, and any team member is able to express concerns about the procedure verification
  • It 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, it has been recognized by both the Joint Commission and the ADA that there does not appear to be a practical or reliable method to actually mark the teeth that are intended for extraction. Therefore, dental procedures are considered exempt from the site marking requirement. Rather, the ADA and Joint Commission recommend 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 diagram 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.

More information about time-out can be found at the following links from the Joint Commission:


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