Improvement Stories

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

Why is the Universal Protocol important to safe patient care?

When you come in for a surgical or invasive procedure you should feel secure and confident in the hospital’s commitment to patient safety and quality care at MGH. One tool the procedure team uses to ensure your safety is the Universal Protocol. This Universal Protocol 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 an outpatient setting--anywhere an invasive procedure is performed. These procedures can range from injections for pain management to major surgical procedures.

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 the MGH, like many hospitals, faces challenges in consistently implementing this procedure. During 2008, there were three incidents at the MGH in which the incorrect application of the Universal Protocol partially contributed to patients having either an injection delivered to the incorrect site, or having an incorrect minor procedure performed.  None of the patients in these cases suffered a serious injury, nor do we anticipate any long-term adverse health consequences for the patients.  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 our Universal Protocol process had to be revised. We brought together a multidisciplinary committee to update the Universal Protocol policy, develop new documentation tools, and implement a method for actually monitoring performance. These updates improved our process and also allowed us to ensure we were meeting all the 2009 requirements for the Universal Protocol established by the Joint Commission.

We encourage patients to be active participants in this Universal protocol process. Patients will be asked by multiple team members what is the procedure they will be having and confirming the exact side and site. For instance you would 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 website Speak Up campaign 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 re-educating our staff about when the universal protocol applies, how to properly perform it, and how to document it.  In addition, we have produced an education video demonstrating the 3 components. And, we are committed to real-time auditing of both the performance and the documentation of the protocol. Finally, we provide feedback to our staff. We are proud of the progress we have made, because it makes our care safer, for you and every patient.


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