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Home > Medical Center > Policies > Medical Center Policy Manual > Provision of Care, Treatment, and Service > Treatment of Patients > Universal Protocol for Preoperative/Pre-Procedure Verification

policy 0250 : Universal Protocol for Preoperative/Pre-Procedure Verification

The University of Virginia Medical Center utilizes a Universal Protocol for verification prior to surgical and invasive procedures, including procedures done in settings other than the operating room. Invasive procedures covered by this policy are those that expose patients to harm, including procedures involving puncture or incision of the skin (excluding venipuncture and peripheral IV placement), or insertion of an instrument or foreign material in the body (excluding indwelling urinary catheters and nasogastric tubes). The purpose of utilizing a Universal Protocol is to prevent wrong site/side, wrong procedure, and wrong person surgery and procedures. There are three required components of the Universal Protocol: 1. Preoperative/Pre-procedure verification 2. Marking the procedural site 3. Final verification "Time out"

File Attachment Downloads

view  |  PDF document icon 0250 Universal Protocol for PreoperativePre-Procedure Verification1001217.pdf — PDF document, 92 KB (94517 bytes)


  1. effective date:

    October 1, 2017
  2. signature(s):

    Scott A. Syverud, MD, President, Clinical Staff
    Pamela M. Sutton-Wallace, CEO, UVA Medical Center