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The universal protocol was designed to prevent wrong site, wrong procedure, and wrong person surgery and has evolved from collaboration among accreditation organizations and professional societies. It was introduced as a standard in 2004.


Definitions and Terms


The protocol is a three-step process including (1) preprocedure identification and verification, (2) site marking, and (3) performance of a “time-out” prior to initiation of the procedure. A mnemonic is “Correct Person, Correct Procedure, and Correct Site.”




  • ▪  Indications in the ICU
    • —Surgical/invasive procedures falling within the scope of universal protocol guidelines include, but are not limited to, cardioversions, cardiac and vascular catheterizations (ie, pulmonary artery catheter placement and vasculare cannulation), transesophageal echocardiography, endoscopies, thoracentesis, chest tube insertions, paracentesis, lumbar puncture, incisions and drainage of wounds, and so on.
  • ▪  Preprocedure patient identification elements
    • —Patient name and date of birth
    • —Medical record number
    • —Verbal identification with patient and/or family member
  • ▪  Preprocedure verification (Figure 3-1)
    • —Procedure confirmation with patient or family/ designee
    • —Consent obtained for procedure
    • —Relevant documentation performed
    • —Indications for procedure
  • ▪  Site marking (Figure 3-2)
    • —Marking of the site is required for procedures involving left/right distinction, multiple structures (ie, fingers and toes) or multiple levels (ie, spinal levels).
    • —Site marking is not required for interventional procedures for which the site is not predetermined, such as arterial line placement, or when procedure is performed under urgent or emergency conditions.
    • —Marking should be unambiguous (ie, use initials of operator or YES).
    • —Marking should be made with ink that remains visible after skin preprocedure.
    • —Marking should remain visible after draping.
  • ▪  Time-out elements checked with all members of procedure team immediately prior to performance of procedure
    • —Verify correct patient identified
    • —Ensure agreement on planned procedure
    • —Verify correct side and site
    • —Verify correct patient position for procedure
    • —Ensure availability of all required equipment

Figure 3-1.
Graphic Jump Location

A sample universal protocol checklist.

Figure 3-2.
Graphic Jump Location

Example of site marking with operator’s initials at the site of left internal jugular, as viewed from the left side of patient’s neck.


Clinical Pearls and Pitfalls


  • ▪  Marking a site with an X is ambiguous—this could be interpreted as “this is the site” or “this is not the site.”
  • ▪  Certain sites (ie, teeth) need not be marked directly, but radiographs should be marked correctly.
  • ▪  Single organ sites need not necessarily be marked (ie, cardiac surgery, caesarian section).


Suggested Reading

The Joint Commission. Universal protocol. (Accessed on May 11, 2008.)

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