Universal Protocol
The Universal Protocol is a set of procedures implemented in 2004 to prevent wrong site, wrong procedure, and wrong patient surgery. It includes three key elements: pre-procedure verification, marking the intended site, and conducting a time-out immediately before starting the procedure. The goal is to use data on adverse events collected by JCI to prevent similar errors in other healthcare organizations.
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Universal Protocol
- 2. UNIVERSAL PROTOCOL The UniversalProtocol is based on the fact that wrong site, wrong procedure, and wrong person surgery can be prevented It became effective in July 2004
- 3. UNIVERSAL PROTOCOL JCI Collectsreports from accredited organizations that have experienced a sentinel event within their organization Data from reports are collected, aggregated, and analyzed to identify root causes of adverse events
- 4. UNIVERSAL PROTOCOL The goalis to use the data to prevent similar errors from occurring in other health care organizations The joint commission found the wrong site surgery to be the third-highest- ranking event
- 5. UNIVERSAL PROTOCOL The protocolincludes many recommended steps but there are three principal elements: a) Pre-procedure verification b) Site marking c) Time out prior to incision
- 6. AT-RISK BEHAVIOR INTHE OR Not checking equipment before use Surgeon entering after prep and drape Surgeon running 2 rooms Multi-tasking from O.R. Relying on memory about the pathology Unannounced substitutions in mid case Continuing to close during sponge search
- 7. O.R. TEAM Be Patient-focused Not surgeon-focused Not workflow-focused Not specialty-focused Not budget-focused Not break-focused
- 8. High Reliability Organizations “CARE “ Commitment by the Leaders Attention to the Task Respond as a Team Effective Communication Safety in surgery require the reliable execution of multiple necessary steps in care by health team working together for the benefit of the patient
- 9. PRE-PROCEDURE VERIFICATION PROCESS Verify thecorrect procedure, for the correct patient, at the correct site. When possible, involve the patient in the verification process.
- 10. PRE-PROCEDURE VERIFICATION PROCESS Identify theitems that must be available for the procedure. Use a standardized list to verify the availability of items for the procedure. At a minimum, these items include: relevant documentation
- 11. labeled diagnostic and radiologytest results that are properly displayed any required blood products, implants, devices, special equipment Match the items that are to be available in the procedure area to the patient. PRE-PROCEDURE VERIFICATION PROCESS
- 12. MARK THE PROCEDURESITE At a minimum, mark the site when there is more than one possible location for the procedure and when performing the procedure in a different location could harm the patient.
- 13. MARK THE PROCEDURESITE For spinal procedures: Mark the general spinal region on the skin. Special intraoperative imaging techniques may be used to locate and mark the exact vertebral level. Mark the site before the procedure is performed.
- 14. MARK THE PROCEDURESITE If possible, involve the patient in the site marking process. The site is marked by a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed.
- 15. MARK THE PROCEDURESITE In limited circumstances, site marking may be delegated to some medical residents, physician assistants (P.A.), or registered nurses (R.N.). Ultimately, the licensed independent practitioner is accountable for the procedure even when delegating site marking.
- 16. MARK THE PROCEDURESITE The mark is unambiguous and is used consistently throughout the organization. The mark is made at or near the procedure site. The mark is sufficiently permanent to be visible after skin preparation and draping.
- 17. MARK THE PROCEDURESITE Adhesive markers are not the sole means of marking the site. For patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site: Use your organization’s written, alternative process to ensure that the correct site is operated on.
- 18. MARK THE PROCEDURESITE Examples of situations that involve alternative processes: mucosal surfaces or perineum minimal access procedures treating a lateralized internal organ, whether percutaneous or through a natural orifice teeth premature infants, for whom the mark may cause a permanent tattoo
- 19. PERFORM A TIME-OUT Theprocedure is not started until all questions or concerns are resolved. 'fail-safe' mode Conduct a time-out immediately before starting the invasive procedure or making the incision.
- 20. PERFORM A TIME-OUT Thetime-out is standardized. The time-out involves the immediate members of the procedure team: the individual performing the procedure, anesthesia providers, circulating nurse, operating room technician, and other active participants who will be participating in the procedure from the beginning.
- 21. PERFORM A TIME-OUT Allrelevant members of the procedure team actively communicate during the time-out. During the time-out, the team members agree, at a minimum, on the following: correct patient identity correct site procedure to be done
- 22. PERFORM A TIME-OUT Whenthe same patient has two or more procedures: If the person performing the procedure changes, another time-out needs to be performed before starting each procedure. Document the completion of the time-out.