– What is the Intention of the Universal Protocol? –
The Universal Protocol’s goal is to ensure patient safety and to prevent surgical errors such as wrong site, wrong procedure, and wrong person surgeries.
Wrong-site surgery occurred at a rate of about 1 in 113,000 operations between 1985 and 2004, according to an AHRQ-supported study.
The Joint Commission adopted a Universal Protocol in July 2004, based on expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery.
The Universal Protocol is applicable to all accredited hospitals, ambulatory care facilities, and office-based surgery centers.
The protocol calls for a time out before beginning surgery, which has been shown to improve teamwork and lower the overall risk of wrong-site surgery.
Is the Universal Protocol Working?
Millions of people require life saving procedures each year in the United States. When going in for surgery, it is a given that someone in the operating room is going to make a wisecrack about writing “operate here” on the patient.
But wrong site, wrong side surgery is no joke, as wrong-site surgeries occur between 1,300 and 2,700 times a year in the United States.
This equates to physicians still performing surgery on the wrong part of the body, performing the wrong procedure, or operating on the wrong patient altogether roughly 40 times a week.
What is the Universal Protocol and who Created it?
The Universal Protocol dictates the minimum requirements physicians must follow to help prevent basic surgical mistakes and is required to be implemented by all accredited hospitals, ambulatory care, and office-based surgical facilities.
In 2004, The Joint Commission released the Universal Protocol.
As a result, the initial seven hospitals involved in rolling out the protocol reduced the number of surgical cases with risks for wrong-site surgery by 46 percent in the scheduling area.
These numbers translate to thousands of people being spared from having dangerous procedures done on the wrong parts of their bodies.
Despite having an effective universal protocol, not all hospitals abide by it, making preventable mistakes even more egregious.
What are the steps a Surgeon must Follow?
The Universal Protocol is a checklist a surgeon must go through with their surgical team before beginning to operate.
The three steps a surgeon must follow before beginning a procedure are:
Conduct a Pre-procedure Verification Process
This process includes verification of the correct surgery and site, as well as verifying the identity of the patient and making sure all necessary tools are available.
Simply put, the surgeon, along with all healthcare professionals present during the procedure, must address missing information or discrepancies before starting.
Mark the Procedure Site
The protocol requires that at minimum, the surgeon must mark the site when there is more than one possible location for the procedure.
The surgeon should clearly label the area where the surgery should be performed with a surgical marker. The surgeon should mark the line that the incision should follow as well as the word “yes.”
Perform a Time-out
All participating members of the surgical team should be present during the time-out and the procedure cannot begin until all questions and concerns are resolved.
The team must verbally agree that the patient is the correct patient, they also ensure that specialists carry out correct procedure, and also perform the surgery at the correct site.
In conclusion, the Joint Commission mandated the Universal Protocol 5 years ago with the goal of increasing patient safety by avoiding procedures at the wrong site or in the wrong patient.