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.
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
- ▪ 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
- ▪ 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
- —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
A sample universal protocol checklist.
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).