Universal Protocol Performance

Guidelines:

• The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery
  • Conduct a pre-procedure verification process
    • Verify the correct procedure, for the correct patient, at the correct site
    • Involve patient in verification process when possible
    • Identify items that must be available for the procedure
  • Mark the procedure 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
    • Site is marked by a licensed independent practitioner who is accountable for the procedure and will be present when the procedure is performed
    • Mark at or near the procedure site
    • Mark is visible after prep/drape
    • Follow organization policies/procedures
  • Perform a time-out
    • Immediately before procedure start
    • Should be standardized
    • Involves immediate members of the procedure team
    • Active communication
    • Members agree at minimum: correct patient identity, correct site, procedure to be done
    • Separate time-out needed for two or more procedures if the person performing the procedure changes

Considerations:

• Pre-procedure verification process
  • Address missing information or discrepancies before starting the procedure
• Mark the procedure site
  • At a minimum, mark the site when more than one possible location
• Time-out
  • The procedure is not started until all questions or concerns are resolved

Nurse’s role:

• Use a standardized list to verify the availability of items for the procedure including:
  • Relevant documentation
    • H&P, signed consent, preanesthesia assessment
  • Labeled diagnostic and radiology test results
    • Radiology images/scans
    • Pathology reports
    • Biopsy reports
    • Ensure they are properly displayed
  • Any required blood products, implants, devices, special equipment
  • Procedure site is marked per policy
• Patient Safety Advocate
  • Active participation in time-out
  • Documentation per organization policy
  • Team communication

Pitfalls:

• Failing to involve the patient in the verification process
• Failing to involve the patient in the site marking process
• Failing to utilize standardized checklists
• Failing to follow organization policy/procedures

Examples:

• What are some situations where an alternative process for site marking might be implemented, per organization policy?
  • Mucosal surfaces or perineum
  • Minimal access procedures treating a lateralized internal organ
  • Teeth
  • Premature infants, for whom the mark may cause permanent tattoo
  • Patient refuses site marking

Linchpins (Key Points):

• Universal protocol performance:
  • Standardized Checklist
  • Standardized Time-out
  • Active Team Participation
  • Active Patient Involvement