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The Universal Protocol

TASA Expert Debra McGuinty RN, BSN, CNOR, CLNC
Most surgical errors are simple and preventable if all operating room team members are on the same page.

Most surgical errors are simple and preventable if all operating room team members are on the same page.

Hraun via iStock

Surgical errors happen every day and lead to numerous types of medical malpractice cases. Most surgical errors are simple and preventable if all operating room team members are on the same page. Communication in a chaotic room with multiple simultaneous actions occurring can often be the root of surgical errors leading to patient injury.

That is why in 2003, the Joint Commission for Accreditation on Healthcare Organizations (JACHO) implemented a multistep practice called “the universal protocol,” which is the standard for surgery today. The goal is to perform the right surgery on the right area and the right patient. The surgical team must start implementing the universal protocol from the pre-operative area to reach this goal, 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 must have an updated history and physical within the last 24 hours or update the history and physical with a signature before the patient can proceed. The surgical consent also must 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 there is any discrepancy, it should be dealt with 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 nuances, but generally, the main points need to be covered. One of the surgical team members 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 the procedure. 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 worldwide indicate a reduction in surgical error and patient mortality due to the implementation of the surgical time out. One study noted that surgical team members had, at one time or another, felt “uncertain of the surgical site or side” (81 percent). Also, 91 percent of the surgical workers surveyed supported a time out. (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. Oct. 9, 2013, doi:10.1186/1471-2482-13-46).

If you become involved in a medical malpractice case that involves a lack of communication leading to a surgical error, make sure you followed this standard and practice. In a compliant operating room, no procedure should continue until team members have their questions answered, and their concerns are resolved.

Please contact me for any surgical medical malpractice needs.

This article discusses issues of general interest and does not give any specific legal or business advice pertaining to any specific circumstances. Before acting upon any of its information, you should obtain appropriate advice from a lawyer or other qualified professional.

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