Implementing the universal protocol hospital-wide

Abstract

Beginning in July 2004, Joint Commission-accredited hospitals were required to adhere to the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery by implementing time outs and site verifications for all invasive procedures. At Children's Hospital Boston, Mass, this requirement necessitated extensive editing of the existing time out and site verification policy and the development of a hospital-wide implementation plan. The Hospital's Universal Protocol champion developed an action plan that involved including nurse and physician representatives from each target area; rolling out the policy; creating materials for advertising the policy; and formulating an education, monitoring, and evaluation plan.