April 7, 2006

Universal protocol: No room for mistakes

An important component of fostering a culture of patient safety in a health care setting is having all health care providers adopt common procedures and safeguards to decrease the risk of harm to patients. This is the goal of the universal protocol that was implemented nationwide in 2004 to help prevent medical injuries and deaths caused by wrong-site, wrong-procedure or wrong-identity of a patient during surgery or other invasive procedures.

Like most hospitals, the MGH has implemented this protocol and has put into place a policy and process for clinicians to follow. The first step is to verify the patient's identity using at least two patient identifiers, which can be the patient's name, birth date or medical record number. Then the intended procedure also is confirmed by checking the procedure consent form, the history or progress notes, nursing assessment and, if applicable, the procedure/operating room schedule.

The procedure site then must be properly marked to identify the area of the patient's body that will undergo the procedure before an incision is made. For example, if a patient is having knee replacement surgery on the left knee, the clinician would write the word "yes" on the patient's left knee area to distinguish the site from the right knee. The patient is an integral part of this safety practice and participates by verifying his or her identity as well as confirming correct procedure, correct side and site.

Before the procedure starts, a "time out" must be initiated by the physician conducting the procedure to give all members of the clinical team an opportunity to perform a final verification of the correct patient, correct procedure, correct side, correct site, correct patient position and availability of correct implants and any special equipment or requirements that are needed for the procedure.

In addition to meeting many national patient safety standards, the universal protocol is an important part of the accreditation process by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). As part of the MGH's JCAHO survey readiness efforts, the universal protocol is featured in the FYI posters that were distributed this week (shown above). For more information about the universal protocol, contact Ruth Bryan, RN, at (617) 726-8945 or at rbryan@partners.org.