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Clinic Policy Manual

Correct Patient, Correct Procedure, Correct Verification Process

Subject: Correct Patient, Correct Procedure, Correct Site, Verification Process Policy
Effective Date: September 2006
Revision Dates: September 2006, September 2016


To ensure the correct patient, receives the correct procedure on the correct site(s)/side

General Policy

  1. All relevant documents (e.g. referral forms, chart notes, medical history, treatment plan, informed consent, properly labeled studies and radiographs) will be available, reviewed and checked for accuracy and lab consistency, before the start of the surgery/procedure.
  2. Consult/referral forms must have the tooth numbers and tooth/teeth description written out and the proper tooth/teeth circled.
  3. All members of the team (attending and/or student, resident, nurse, and dental assistant) will conduct a final verification (time-out) before the procedure begins.


1. Identification and verification of the correct patient, procedure and site(s)/side will occur:

a. At the time the procedure is scheduled
b. At time patient is being seated
c. Anytime the responsibility for care of the patient is transferred to another caregiver
d. Prior to the treatment team performing the procedure

2. Site(s)/side marking

a. Because dental procedures are difficult to definitively site mark the following must occur:

i. Review the dental record including the medical history, consult/referral forms, laboratory findings, appropriate charts, radiographs and informed consent form(s). Make sure all information is consistent and matches with the radiographs.
ii. Confirm with the patient the specific procedure that is to be performed prior to any anesthesia or sedation.
iii. Ensure the radiographs are properly oriented and visually that the correct tooth/teeth have been charted.
iv. Conduct a final verification to verify patient, tooth and procedure with an assistant or patient at the time of the extraction(two person rule)

3. Final Verification (time out)

a. All members of the dental team (e.g. dentist, student, resident) involved in the procedure will conduct a final verification (time out) for procedures meeting one or more of the following criteria:

i. Informed consent
ii. Moderate Sedation is administered
iii. Non-reversible procedure

b. The attending dentist must be present for the final verification.

c. All member() present immediately prior to the procedure must verbally confirm the following:

i. Correct patient
ii. Correct procedure
iii. Correct site
iv. Correct position
v. Availability of correct implants and special equipment or special requirements
vi. Prophylactic antibiotics have been given (if ordered)

d. Final verification (timeout) is documented on the progress notes/surgery form as “Timeout Performed at____ Hours” by the person completing the chart entry and followed by an attending signature.


In Case of an Adverse Event in any procedure

  1. Immediately notify the senior faculty member or the Clinic Director in the department.
  2. The Clinic Director will notify Health Sciences Risk Management (206-598-6303)
  3. The faculty member with Health Sciences Risk Management or Clinic Director will inform the patient or family of the event as soon as possible.
  4. The Dental team involved in a School of Dentistry patient event will complete a Patient Event Form available online.
  5. For patient events occurring at UWMC, the event should be reported in the Patient Safety Net system accessible to practitioners who have UWMC credentials (e.g. oral surgeons.)

Dean of UW SOD:

Joel Berg, Dean of the UW School of Dentistry