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Universal Protocol
Components of the Joint Commission's Universal Protocol
| Question | Answer |
|---|---|
| Universal Protocol | A code of correct conduct intended to prevent wrong site surgery |
| This is not a step of the Universal Protocol | Wash hands before and after contact with blood or other infectious material |
| A document which needs to be verified prior to an invasive procedure | Diagnostic or radiology test results |
| Never Event | Serious, costly, preventable |
| Pre-procedure verification | Ensures all relevant documents, related information, equipment are available and correct |
| Invasive procedure | Any procedure involving the puncture or incision of the skin, the insertion of an instrument, or the insertion of foreign material into the body |
| Time Out | Intentional pause immediately prior to the start of a procedure intended as a final verification of the Universal Protocol |
| Marking of the procedure site | Considers laterality, surface, level, or lesion and is unambiguous |
| Licensed independent practitioner | Person who marks the site and will be performing the procedure |
| The marker | Sufficiently permanent to remain visible after skin prep and draping |
| Root cause analysis | Investigation to determine what happened, why it happened, and how it can be prevented from happening again |
| Never event | Another term for sentinel event |
| Three | Number of components of the Universal Protocol |
| Communication | Surgical team members must feel free and empowered to speak up about any concerns or discrepancies during the Time Out |
| Focus | All surgical team members must stop all activity and be engaged in the Time Out |
| Standardized checklist | Organization-specific list which enables the surgical team to verify availability of items for the procedure |
| Perioperative nurse | Plans, coordinates, delivers, and evaluates nursing care to surgical patients |
| Nursing process | Used by perioperative registered nurse circulators to achieve optimal outcomes for surgical patients |
| One | The minimum number of perioperative registered nurses dedicated to each surgical patient |
| Evidence-based practice | The foundation of perioperative nursing practice |
| Joint Commission | Organization which promotes the Universal Protocol and develops National Patient Safety Goals |
| Perioperative setting | Potentially hazardous clinical environment which could lead to adverse patient outcomes |
| Patient safety | Fundamental priority of the perioperative setting |
| Just culture | Environment where individuals are accountable for their actions |
| Learning culture | Environment which fosters learning resulting from the study of evidence-based practice and safety research |
| Disruptive behavior | Not tolerated in the perioperative environment |
| Essential partners | Patients and their family members |
Created by:
piper1016
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