In March 2003, a system-wide summit of four community hospitals in Northern Virginia was conducted to implement The Joint Commission's Universal Protocol for Prevention of Wrong Site, Wrong Procedure, Wrong Person Surgery.1 The adoption of a verification process, or "boarding pass," was necessary to ensure successful execution of this initiative.

Every patient must have a boarding pass to validate each component of preparation including the preoperative verification process, marking the operative site, and taking a "time out" before starting the procedure.1

The boarding pass process was standardized across the health system for both inpatient and outpatient procedures. Applicable procedures included:

* all surgical and invasive procedures with the exception of venipunctures, I.V. lines, arterial lines, nasogastric tubes, urinary catheters, or contrast media administration

* procedures that require anesthesia or sedation

* procedures requiring informed consent.

The boarding pass isn't required in an emergency. Nonetheless, physicians are required to document any emergency circumstances in the progress notes.

Frances Vasaly is a clinical outcomes specialist, Inova Fairfax Hospital, Falls Church, Va.

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