OASKBROOK TERRACE, Ill. -- The Board of Commissioners of
the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
last week approved a "Universal Protocol" for preventing wrong site, wrong
procedure and wrong person surgery. Compliance with the Universal Protocol
by all accredited organizations that provide surgical services will be
required beginning on July 1, 2004.
The Universal Protocol draws upon, and expands and integrates, a series of
existing requirements under the 2003 and 2004 National Patient Safety
Goals. It will be applicable to all operative and other invasive
procedures. The principal components of the Universal Protocol include:
(1) the pre-operative verification process; (2) marking of the operative
site; (3) taking a "time out" immediately before starting the procedure;
and (4) adaptation of the requirements to non-operating room settings,
including bedside procedures.
The Universal Protocol is the consensus product of a national Summit on
Wrong Site Surgery convened last spring by the Joint Commission, the
American Medical Association, the American Hospital Association, the
American College of Physicians, the American College of Surgeons, the
American Dental Association and the American Academy of Orthopaedic
Surgeons. Summit participants included leaders from other medical and
surgical specialty organizations, nursing organizations and provider
associations, among others. The Summit participants concluded that wrong
site, wrong procedure and wrong person surgery can be prevented and that a
Universal Protocol is needed to help accomplish this goal.
"This Universal Protocol asks health care organizations to set a goal of
zero-tolerance for surgeries on the wrong site or on the wrong person, or
the performance of the wrong surgical procedure," says Dennis S. O'Leary,
MD, president of JCAHO. "These are occurrences which simply should never
A three-week public comment period that concluded earlier this month
generated more than 3,000 responses from surgeons, nurses and other health
care professionals, which were overwhelmingly in support of the Universal
Protocol. The comments also provided the basis for a number of
refinements to the protocol.
Despite widespread acknowledgement that surgeries on the wrong site or on
the wrong person, or the wrong surgical procedure should never happen, the
Joint Commission continues to receive five to eight new reports of wrong
site surgery every month from organizations that provide surgical
services. These reports are almost all shared with the Joint Commission
on a voluntary basis.
The Joint Commission plans to seek formal endorsement of the Universal
Protocol from all of the organizations that participated in the Wrong Site
Surgery Summit, as well as other professional leadership organizations
having interest in this issue. This solicitation of support will be
initiated in the immediate future.