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Implementing the universal protocol hospital-wide

Elizabeth Norton1

  • 1Children's Hospital Boston, Mass., USA.

AORN Journal
|June 15, 2007
PubMed

Insights

Hospitals must implement the Universal Protocol for preventing surgical errors, including time outs and site verification. This involved revising policies and creating a hospital-wide plan for successful implementation.

Area of Science:

  • Healthcare Policy
  • Patient Safety
  • Surgical Protocols

Background:

  • Joint Commission mandated the Universal Protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery starting July 2004.
  • Accredited hospitals must implement time outs and site verifications for all invasive procedures.

Purpose of the Study:

  • To describe the development and implementation of a hospital-wide plan for the Universal Protocol.
  • To outline the necessary policy revisions and action plan for compliance.

Main Methods:

  • Editing existing time out and site verification policies.
  • Developing a hospital-wide implementation plan.
  • Creating an action plan involving multidisciplinary teams, policy rollout, educational materials, and a monitoring/evaluation strategy.

Main Results:

  • A comprehensive action plan was developed by the Universal Protocol champion.
  • Involvement of nurse and physician representatives from target areas was crucial.
  • A strategy for education, monitoring, and evaluation was formulated.

Conclusions:

  • Successful implementation of the Universal Protocol requires significant policy revision and a structured, hospital-wide approach.
  • Multidisciplinary team involvement and robust education/monitoring plans are key to patient safety initiatives.

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