JCAHO Universal Protocol

Universal Protocol For Eliminating Wrong Site, Wrong Procedure, Wrong Person Surgery

Wrong site, wrong procedure, wrong person surgery can be eliminated. This universal protocol is intended to achieve that goal. It is based on the consensus of experts from the relevant clinical specialties and professional disciplines and endorsed by the American Academy of Orthopaedic Surgeons.

In developing this protocol, consensus was reached on the following principles:

• Wrong site, wrong procedure, wrong person surgery and must be prevented.
• A robust approach-using multiple, complementary strategies-is necessary to achieve the goal of eliminating wrong site, wrong procedure, wrong person surgery.
• Active involvement and effective communication among all members of the surgical team is important for success.
• To the extent possible, the patient (or legally designated representative) should be involved in the process.
• Consistent implementation of a standardized approach using a universal, consensus-based protocol will be most effective.
• The protocol should be flexible enough to allow for implementation with appropriate adaptation when required to meet specific patient needs.
• A requirement for site marking should focus on cases involving right/left distinction, multiple structures (fingers, toes), or levels (spine).
• The universal protocol should be applicable or adaptable to all operative and other invasive procedures that expose patients to harm, including procedures done in settings other than the operating room.

In concert with these principles, the following steps, taken together, comprise the Universal Protocol for eliminating wrong site, wrong procedure, wrong person surgery:

• Pre-operative verification process
  • Purpose: To ensure that all of the relevant documents and studies are available prior to the start of the procedure and that they have been reviewed and are consistent with each other and with the patient's expectations and with the team's understanding of the intended patient, procedure, site and, as applicable, any implants. Missing information or discrepancies must be addressed before starting the procedure.
  • Process: An ongoing process of information gathering and verification, beginning with the determination to do the procedure, continuing through all settings and interventions involved in the preoperative preparation of the patient, up to and including the "time out" just before the start of the procedure.
• Marking the operative site
  • Purpose: To identify unambiguously the intended site of incision or insertion.
  • Process: For procedures involving right/left distinction, multiple structures (such as fingers and toes), or multiple levels (as in spinal procedures), the intended site should be marked such that the mark will be visible after the patient has been prepped and draped.
• "Time out" immediately before starting the procedure
  • Purpose: To conduct a final verification of the correct patient, procedure, site and, as applicable, implants.
  • Process: Active communication among all members of the surgical/procedure team, consistently initiated by a designated member of the team, conducted in a "fail-safe" mode, i.e., the procedure is not started until any questions or concerns are resolved.