Universal Protocol
November 13, 2009

Updated Universal Protocol:

The 2010 Universal Protocol are now accessible as part of the National Patient Safety Goal chapter from your accreditation manual.

2009 Universal Protocol

Below are links to program-specific versions of the updated Universal Protocol, which is effective January 1, 2009. The Universal Protocol was revised based on feedback received at the Wrong Site Surgery Summit in 2007. The updated Protocol has new or deleted elements of performance. In addition, the Universal Protocol includes improvements emanating from the Standards Improvement Initiative, including the new numbering system and minor language changes for consistency. The new numbering format was designed to enable sorting electronically (for the new E-ditions of the manuals) and to accommodate the addition of new requirements. Under the new numbering system, each requirement is assigned a six-digit number that designates its place in the chapter.

2009 FAQs about the Universal Protocol -  Now Posted Under Standards FAQs 

Universal Protocol

Universal Protocol Poster

Download English Version (PDF)  -   Download poster artwork file
(Requires Adobe Reader)                   (Requires Mac Quark 6.0+)

Download Spanish Version (PDF) -   Download poster artwork file
(Requires Adobe Reader)                   (Requires Mac Quark 6.0+)

There are NO copyright or reprinting permissions required for the Speak Up materials or copy. In references to the materials or copy, we do ask that The Joint Commission be credited as the source for the materials or copy.   For more information see "About the Speak Up Program." 

Additional resources on wrong site surgery:

For more information, contact the Standards Interpretation Group at (630) 792-5900 or submit your questions to our online question form.