Friday, May 18, 2012

Universal protocol: ‘Nothing starts until we all stop’


If asked to give an example of where the universal protocol takes place, most MGHers might describe an operating room (OR) setting. But the universal protocol – the three steps required before any operative or invasive procedure to ensure the correct patient is verified for the correct procedure on the correct site – is required in many nonsurgical settings, whether at the bedside for a paracentesis procedure or in the electrophysiology lab for a cardiac catheter ablation.

Interventional radiology is another beyond-the-OR location where the universal protocol is required. Melissa Chittle, PA, recalls placing a central venous catheter, or port-a-catheter, in a patient who needed chemotherapy. Despite the added pressure of the presence of Joint Commission consultants, she followed each step of the universal protocol perfectly.

“Universal protocol is extremely important to me, and the only way to always remember to do it is to do the same thing the same way every time. Consistency is key,” says Chittle. “By following the universal protocol for all procedures – even for minor procedures or procedures that are very straightforward – you can make sure you are prepared for cases that may be more complex.”

Although the universal protocol has been the standard for a number of years, there are still challenges with consistency. For this reason, it is one of the top four hospitalwide priorities for performance improvement at the MGH in 2012.

The three key components of the universal protocol are:

1) Pre-procedure verification, which includes verifying the patient’s identity, confirming that all documents match current information and making sure procedural consent is accurately completed and signed;

2) Marking of the procedural site; and

3) The hard stop time-out, when all team members must completely stop what they are doing, make eye contact with one another and actively review all information.

For more information about the universal protocol, contact Ruth Bryan, RN, MSN, at 617-726-8945 or or visit

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