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Universal Protocol

Components of the Joint Commission's Universal Protocol

QuestionAnswer
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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