The Universal Protocol

TASA ID: 16893

Surgical errors happen every day, and lead to numerous types of medical malpractice cases. Most surgical errors are simple things that could have been prevented if all of the members of the operating room team were on the “same page”. Communication in a hectic room with multiple things going on at the same time can often be the root of surgical errors that lead to patient injury.

That is why the Joint Commission for Accreditation on Healthcare Organizations (JACHO) implemented a multi-step practice called “the universal protocol” back in 2003 that is the standard for surgery today. The goal is to perform the right surgery on right site and on the right patient. This requires the surgical team to start implementing this standard from the pre-operative area, then onto surgery.

The patient first needs to have the surgical site marked by the operating physician in the pre-operative area. Typically, the surgeon needs to have an updated history and physical within the time period of the last 24 hours, or update the history and physical with a signature before the patient can proceed. The surgical consent also needs to be complete with the procedure and signatures of the surgeon, the patient and a witness. This consent usually needs to have a date no earlier than 30 days before surgery.

Upon meeting and speaking with the patient, the pre-op nurse, operative nurse, anesthesia provider, and surgeon will all verify with the patient verbally the agreed upon procedure, and site. If any discrepancy is noted, it needs to be sorted out before transfer into the operating room.

Before an incision is made, and preferably before anesthesia induction, a surgical “time out” is performed. Each institution has its own nuances, but generally the main points need to be covered. One of the surgical team needs to begin the time out procedure by stating the patient’s name, surgery, site, antibiotics to be administered, special needs as far as supplies or implants, and any miscellaneous points, including special post-operative considerations. Ideally, each person in the room will verbally agree to what is being done. All team members must be quiet, listen and participate.

This verification process is all in the name of patient safety, and for this reason, should not be looked at as a “waste of time” or nonsensical triviality. Several studies done around the globe indicate a reduction in surgical error and patient mortality due to the implementation of the surgical time out. One study indicated that surgical team members had, at one time or other, felt “uncertain of the surgical site or side” (81%), and a time out was supported by 91% of the surgical workers surveyed (Haugen, AS, BMC Surg. 2013).

If you find yourself involved in a medical malpractice case which involves a lack of communication leading to surgical error, you need to make sure this standard and practice was followed. In a compliant operating room, no procedure should continue until all questions by team members are answered and their concerns resolved. Please contact me for any surgical medical malpractice needs at wwwpeaklegalnurse.com.

Haugen AS, Murugesh S, Haaverstad R, Eide GE, Søfteland E. A survey of surgical team members' perceptions of near misses and attitudes towards Time Out protocols. BMC Surg. 2013;13:46. Published 2013 Oct 9. doi:10.1186/1471-2482-13-46

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