Universal Protocol Established for Preventing Wrong-Site, Wrong-Procedure, Wrong-Person Surgery


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.

Source: JCAHO

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