“Oops. Doctor, I think we have the wrong patient here.” No one wants to hear those words.

Wrong site surgery refers to operating on the wrong body part, such as the left side of the body instead of the right, the wrong structures such as the wrong fingers or toes, or the wrong spinal level.

Wrong procedure refers to performing an incorrect procedure.

Wrong patient refers to the chilling scenario of operating on the wrong patient. All of these are never events for which the hospital will receive no reimbursement for any care associated with the error.

Universal Protocol

The Joint Commission developed a Universal Protocol that applies to all operative and other invasive procedures. The Universal Protocol is in place to prevent wrong site, wrong procedure and wrong patient surgery. The Universal Protocol has three parts:

• A preoperative verification process
• Marking the operative site
• Taking a time out immediately before starting the procedure

Components of Universal Protocol

Let’s look at each of these pieces.

Preoperative Verification

The preoperative verification process ensures that the right patient is identified. Staff should use those patient identifiers discussed in a previous blog. They must verify they have the right patient. The patient is involved, whenever possible, in the process. In emergent, life-threatening situations, the responsible physician has likely been involved in the care up to the point and in a position to identify the patient.

Marking the Site

With the assistance of the patient, the surgeon verifies the surgical site and marks it in a manner that will be visible after the patient is draped. Marking may consist of using a pen so the surgeon can sign his or her initials, or writing “yes”. The use of an X is discouraged because some members of the surgical team have interpreted this as “do not operate on this spot.”

Time Out

A time out is completed immediately before the procedure begins. This is when the staff verify the correct patient, procedure, and site. Any questions or concerns must be resolved before proceeding.

Best Practices

Here are some tips about how healthcare providers can help make the Universal Protocol successful in preventing wrong site, wrong procedure and wrong patient procedures:

• If possible, indicate the site of the surgery when it is scheduled, such as “arthroscopy right knee.”
• Don’t allow the pressure to get a procedure or operation started bypass the steps of the Universal Protocol.
• Pause before the procedure begins to verify all steps of the Universal Protocol have been carried out.
• Consistently implement a standardized approach.
• Obtain the active involvement of the physician or provider who is performing the procedure or surgery.
• To the extent possible, actively involve the patient in verifying his or her identity, intended procedure and the specific site of the surgery (which side and part of the body).
• Strive for a 100% perfect process.

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