Q. What procedures fall within the scope of the Universal Protocol?
A. The Protocol is not limited to operating rooms; it is relevant to all settings where procedures are performed. The Protocol and its implementation guidelines apply to all operative and other invasive procedures that expose patients to more than minimal risk. The Joint Commission’s glossary defines invasive procedures as involving “the puncture or incision of the skin, insertion of an instrument, or insertion of foreign material into the body. Invasive procedures may be performed for diagnostic or treatment-related purposes.”
While The Joint Commission does not specifically define the term minimal risk, certain routine "minor" procedures such as venipuncture, peripheral intravenous line placement, insertion of a naso-gastric tube or urinary bladder catheter are not within the scope of the Protocol. However, examples of procedures such as PICC line and all central line insertion, chest tube insertion and other similar types of common procedures are included. Please note that procedures specifically excluded from the Universal Protocol are electroconvulsive therapy (ECT), closed reduction, radiation oncology, lithotripsy and performance of dialysis (excluding insertion of dialysis catheters).
The overall purpose of the Universal Protocol is to improve patient safety and prevent procedural errors. Based upon the statements of the preceding paragraphs, and with a focus on safety, each organization is expected to clearly define for itself which procedures will fall within the Protocol. All healthcare workers involved in operative and other invasive procedures should know for which procedures the Protocol must be utilized.