The Joint Commission is a non-profit, independent organization that accredits and certifies more than 19,000 health care organizations and programs in the United States. The Joint Commission Board of Commissioners promulgated the “Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery” (“Universal Protocol”) that was effective as of July 1, 2004 for all hospitals, ambulatory care facilities, and office-based surgery facilities accredited by the Joint Commission.
The Universal Protocol addresses the occurrences of wrong site, wrong procedure, and wrong person surgeries in Joint Commission-accredited facilities. The three principal components of the Universal Protocol are a pre-procedure verification process, procedure site marking, and performance of a mandatory time-out before the procedure is started.
The Pre-Procedure Verification Process
The pre-procedure verification process is intended to address any missing information or discrepancies before starting the procedure by verifying the correct procedure for the correct patient at the correct site for the procedure; by involving the patient in the verification process, when possible; by identifying all items that are required to be available for the procedure; and, by using a standardized list to verify the availability of all items that are required to be available for the procedure, including relevant documentation, labeled test results that are properly displayed, and any blood products, implants, devices, and special equipment that are required for the procedure. The items in the procedure area must be matched to the particular patient.
Marking The Procedure Site
When there is more than one possible site for the procedure and if the performance of the procedure on the wrong site may cause harm to the patient, the procedure site must be marked before the procedure is begun by the appropriate practitioner who will be present for the procedure and who is accountable for the procedure, and the patient must be involved in marking the procedure site, if possible. The mark must be made at or near the procedure site in an unambiguous and consistent manner used throughout the facility in such a way that the mark is visible after the skin is prepared and after surgical draping.
Perform A Time-Out
The procedure may not be started until a standardized time-out is performed so that all questions and concerns are resolved prior to the procedure. All of the immediate members of the procedure team are involved in the time-out. During the time-out, the correct patient identity, the correct procedure site, and the correct procedure to be performed must be agreed upon by all members of the procedure team before the procedure is begun. If more than one procedure is to be performed, a time-out must be performed before beginning another procedure. The time-out must be documented.
By strictly adhering to and complying with the Universal Protocol, surgeons, hospitals, and other facilities may reduce their risk of medical malpractice lawsuits for common surgical errors and surgical mistakes that are often indefensible.
If you or a loved one have been injured as a result of a surgical mistake, surgical error, or surgical malpractice, you should promptly seek the advice of a local medical malpractice attorney to learn about your rights.
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