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Published 12/1/2009
Dirk H. Alander, MD; David B. Carmack, MD

Joint Commission updates requirements for Universal Protocol

Since the publication of the Universal Protocol 2009 update, the AAOS leadership and the AAOS Patient Safety Committee have continued a dialogue with the Joint Commission (JC). (See “The Universal Protocol—Can’t love it or leave it!AAOS Now, September 2009.) As a result, the Protocol was revised twice during 2009, and a new update will be effective as part of the 2010 patient safety goals.

The basic tenets of the Universal Protocol remain consistent: preoperative verification, site marking, and a time-out prior to incision. But there is now more flexibility in how these tenets are implemented. The following points from the JC’s “final” published Universal Protocol (Fall 2009) can be of immediate use to the fellowship:

1. Preoperative verification includes confirming patient identity, correct site, and correct procedure.
a) Timing (when this verification occurs) is under local control.
b) Location (where this verification occurs) is also under local control.

2. Marking the surgical site can be done by the following individuals:
a) Operating surgeon
b) Participating resident
c) Participating licensed practitioner (including physician assistant or nurse practitioner) with a collaborative or supervisory agreement with the surgeon (Determination of this application is under local control.)

3. Only one time-out is required, just prior to the incision.
a) Local hospitals may require more than one time-out.
b) Time-out must be repeated with a new surgeon or procedure.

The JC has kept the major principles of the original Universal Protocol in place but has provided local hospital systems with more flexibility in implementing them. As a result, participation by orthopaedic surgeons on local hospital surgical committees is important.

More details are available at the AAOS patient safety Web site and at the JC Web site. Contact the AAOS Patient Safety Committee with questions or suggestions.

Dirk H. Alander, MD, and David B. Carmack, MD, are members of the AAOS Patient Safety Committee.