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What is the Universal Protocol?

On Behalf of | Jan 21, 2022 | blog, Medical Malpractice |

There are some basic safety measures every surgical team should adhere to before each surgery. According to the Joint Commission, these steps are the Universal Protocol.

The Joint Commission created the process to help avoid surgical errors and reduce common mistakes that could harm patients. It is a basic checklist that the surgeon should lead the team through before beginning to operate on a patient.

Pre-procedure verification

The pre-procedure verification process requires checking all documentation and verifying the identity of the patient. Ideally, the patient will be conscious at this time to answer questions and verify the information. Everyone in the room should ensure their paperwork is accurate and they know who this patient is and why he or she in is the operating room. If the team finds missing or incorrect information, they must correct it before proceeding.

Marking of the site

The next step is to mark the surgical site according to the documentation. If it is a site that could have more than one location, the surgeon should verify the correct location and label the surgical and non-surgical sites. For example, if the patient is having surgery on the right arm, then the team should mark the right arm as the correct site and the left arm as the incorrect site. During marking, the surgeon should also clearly define the cut line and add labels.

Time out

The final step in the process is a time-out. This pause before the surgery is time for everyone to ensure they are on the right page and ready for the procedure. If anyone has questions, they can ask them at this time. Everyone who is part of the surgical team should be present. Any last-minute instructions should also be given at this time. If there are lingering concerns, they need handling at this time.

Before beginning the surgery, the team should do one final quick review of the surgical site and patient information. Conducting the Universal Protocol should occur before every single surgery.

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