Improvement Stories

Universal Protocol: The right procedure, right patient, right place.

Why is the Universal Protocol important to safe patient care?

When you visit MGH for a surgical or invasive procedure, you should feel secure and confident in the hospital’s commitment to patient safety and quality care. One tool that we use to ensure your safety is the Universal Protocol. This is our safety net to prevent patient harm by ensuring that the correct procedure is performed on the correct patient and on the correct side and site. It is applicable in both inpatient and outpatient settings - anywhere invasive procedures are performed. These procedures can range from injections for pain management to major surgical operations.

The Universal Protocol has three key components that must be performed and documented: 1) pre-procedure verification, 2) site marking, and 3) a hard stop time-out. Its value to patient safety is clear, but like many hospitals, MGH faces challenges in consistently implementing this best practice. During 2008, there were three incidents at MGH that involved incorrect application of the Universal Protocol. None of the patients in these cases suffered a serious injury, nor do we anticipate any long-term adverse health consequences. All three incidents were immediately disclosed to the patients involved and reported to the Massachusetts Department of Public Health, as required by law.

What are we doing about it?

We investigated each incident and decided that our Universal Protocol process needed to be revised. We convened a multidisciplinary committee to update the Universal Protocol policy, develop new documentation tools, and implement a method for monitoring performance. These changes improved our process and met the 2009 requirements established by the Joint Commission.

We strongly encourage patients to be active participants in the Universal Protocol process. Before a procedure, patients are asked by multiple team members to identify the service they are having and confirm the exact side and site. For instance, a patient might answer: "My name is Mary Smith, and I am having a right sided lung biopsy in Radiology". Patients can learn more about their role in the Universal Protocol by visiting the Joint Commission Speak Up campaign website and downloading the brochure entitled Help Avoid Mistakes in your Surgery.( )

Where are we now?

We believe our Universal Protocol process makes patient care safer. We have accomplished this by completing a comprehensive campaign to reeducate staff about when protocol applies, how to properly perform it, and how to document it. As part of this effort, we produced an educational video demonstrating each of the three components. Finally, we conduct real-time auditing of protocol adherence and documentation, and provide feedback to staff. We are proud of the progress we have made, because it makes our care safer for every patient.


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