Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery

Abstract

Background: The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery was approved by the Joint Commission Board of Commissioners in July 2003 and became effective July 1, 2004. It requires the performance of a preprocedural verification process, marking of the procedure site, and performing a "time out" immediately before the start of a procedure. Compliance with the Universal Protocol requirements remains cumbersome because of the inherent characteristics of the surgical work flow process.

Methods: By working directly with the Joint Commission, their medical staff, perioperative nursing staff, and members of the hospital quality department, the authors were able to develop an innovative anatomic marking form, which serves as a surrogate for marking patients.

Results: The marking form has been used on 112,500 patients over 4.5 years, with a single implementation error that led to minimal patient harm.

Conclusion: This article describes the development of the anatomic marking form and the practical implications the process has on patient safety.