ellucid Policy Library, MCN Healthcare's library of policies, procedures, forms, and competencies to help hospitals, HME, medical office and other health care organizations meet JCAHO and CMS accreditation compliance. MCN Healthcare

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Tip of the Week

Interventional Radiology and Site Marking

Question:

Does the Joint Commission require site marking for interventional radiology procedures?

Answer:

The Universal Protocol applies to all surgical and nonsurgical invasive procedures.  Universal Protocol, UP.01.02.01 states the following:

  • "Identify those procedures that require marking of the incision or insertion site. At a minimum, sites are marked when there is more than one possible location for the procedure and when performing the procedure in a different location would negatively affect quality or safety."