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Facts about the Universal Protocol

January 17, 2014

The Joint Commission Board of Commissioners originally approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™ in July 2003, and it became effective July 1, 2004 for all accredited hospitals, ambulatory care and office-based surgery facilities. The Universal Protocol was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery and other procedures in Joint Commission accredited organizations. The Universal Protocol drew upon, and expanded and integrated, a series of requirements under The Joint Commission’s 2003 and 2004 National Patient Safety Goals. The three principal components of the Universal Protocol include a preprocedure verification, site marking, and a time out.

Development of the Universal Protocol
Wrong site, wrong procedure and wrong person surgeries are sentinel events (an unexpected occurrence involving death or serious physical or psychological injury) that are tracked through The Joint Commission sentinel event database. The Joint Commission has issued two Sentinel Event Alert newsletters on the subject of wrong site surgery; the first was published August 28, 1998, and the follow-up was published December 5, 2001. In response to continuing reports of wrong site, wrong procedure and wrong person surgery, Joint Commission leadership agreed that it was necessary to get key organizations involved in efforts to prevent wrong site, wrong procedure, and wrong person surgery.

On May 9, 2003, The Joint Commission hosted a Wrong Site Surgery Summit, with the goal of obtaining consensus on the adoption of a “universal protocol” for preventing wrong site, wrong procedure and wrong person surgery. The Summit was hosted by The Joint Commission in collaboration with: American Medical Association, American Hospital Association, American College of Physicians, American College of Surgeons, American Dental Association, and American Academy of Orthopaedic Surgeons. The leaders of more than 30 other professional groups participated in the Summit. Summit participants agreed that a universal protocol would help prevent the occurrence of wrong site, wrong procedure and wrong person surgery; that the protocol should be specific, so as to eliminate confusion about site marking and facilitate communication among surgical team members; and that it should provide the flexibility needed for unique surgical situations.

The Joint Commission pursued broad consensus on the draft of the Universal Protocol in order to make it valuable and useful to the majority of surgical situations and staff. The public comment period generated more than 3,000 responses from surgeons, nurses and other healthcare professionals, which were overwhelmingly in support of the Universal Protocol. The comments also provided the basis for a number of refinements to the protocol. Following approval by the Board, The Joint Commission sought endorsement of the protocol from leading professional associations and organizations. Approximately 51 professional associations and organizations endorsed the original Universal Protocol.

The Universal Protocol was revised for 2010 based on feedback from the field and other stakeholders. The intent of the revisions was to address patient safety issues while allowing organizations flexibility in applying the requirements within existing work processes, given the diversity of organizations that need to follow the Universal Protocol.

The Universal Protocol is available on this website. For more information, contact the Standards Interpretation Group at 630-792-5900, or submit your question on our online question form.


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