Joint Commission universal protocol procedure template

1Purpose

1. 1.1This procedure sets out how [Clinic name] prevents wrong site, wrong procedure and wrong person procedures.

2Preprocedure verification

1. 2.1Before the procedure, the team confirms the patient's identity with two identifiers, the procedure, the site and the signed consent.
2. 2.2The relevant records, images and results are present and match the patient.

3Marking the site

1. 3.1The person doing the procedure marks the site before the procedure, where laterality, levels or multiple structures apply.

4The time-out

1. 4.1Immediately before the procedure starts, the whole team stops and confirms the patient, the procedure and the site.
2. 4.2The time-out is recorded in the procedure note, with the time and the names of the team.

5Review

1. 5.1[Name, role] reviews this document every [12] months, and sooner after an incident, a complaint or a change in the regulator's requirements.
2. 5.2Each review is recorded with the date, the reviewer and what changed, and the previous version is kept.
3. 5.3Staff are told of each change, and their acknowledgement is recorded.

6Where this sits in the Joint Commission framework

• Universal ProtocolUP.01.01.01 Conduct a preprocedure verification process.
  UP.01.02.01 Mark the procedure site.
  UP.01.03.01 A time-out is performed before the procedure.