Joint Commission

The Joint Commission requires a time out be performed prior to the initiation of moderate to deep sedation. The nurse or tech must initiates the time out process with all sedation caregivers present. The staff member then reviews the following items with all sedation staff: correct patient, correct side/site, correct procedure, correct patient position, correct equipment and supplies, agreement or consent for procedure obtained and then ensures that all staff participating is documented. This process is key to improving patient safety by ensuring we are performing sedation correctly and on the correct patient. If your site is not performing time out for sedations then please refer to the Joint Commission Standard UP Requirement 1C, EP2.