General Universal Protocol
This is applicable to all invasive procedures and in all patient care areas and designed to eliminate wrong site, wrong procedure, and wrong patient surgeries.
What is universal protocol?
Patients must be identified using at least 2 of these 3 identifiers.
What are patient name, birthday, and MRN?
This must be done if the surgical site is not marked in pre-op.
What is do not proceed to the operating room, stop the line, and contact the provider?
What is time out?
This person holds primary responsibility for acquiring informed consent from the patient or patient's guardian.
Who is the surgeon?
This should happen if there is a consent discrepancy such as different site, different procedure, or different patient.
What is stop the line and contact the provider?
This must be done prior to time out if the site marking is not visible after the surgical site is prepped and draped.
What is re-marking of the procedure site?
This must happen if the surgeon leaves the room after time-out before performing another procedure.
What is another time-out?
This organization established the Universal Protocol in 2004.
What is The Joint Commission?
The timeframe a surgical consent is good for.
What is 90 days?
Per the AORN guidelines, these are required to be on every site marking before the patient enters the OR suite.
What are the surgeon's initials?
These activities can continue to be done as a surgical timeout is happening.
What is nothing?
These are the three mandatory elements of the universal protocol.
What are pre-procedure verification, site marking if required, and time out?
These 4 items should be confirmed to be available and ready prior to the patient entering the operating room.
What are the correct equipment, correct instrumentation, correct supplies, and correct implants if required?
The surgeon's site marking must still be visible after prepping and draping to help prevent this type of event.
What is wrong-site surgery?
This activity must be performed prior to completing closure of an operative site. It includes all procedures performed, confirmation that surgical counts are correct, verification of specimens if applicable, estimated blood loss, review of any anesthesia concerns, and confirmation of post-op patient destination.
What is the final safety pause?