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The Universal Protocol: Pitfalls and Pearls

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Patient Safety in Surgery

Abstract

As we are now in the 10th year of the Universal Protocol’s implementation in the United States, it is time for critical assessment of the protocol’s impact on patient safety related to the incidence of preventable “never events”. The current book chapter discusses potential shortcomings and pitfalls of the Universal Protocol, and provides recommendations on how to circumvent specific inherent vulnerabilities, in order to improve the effectiveness and quality of this widely established patient safety protocol.

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References

  1. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, et al. A surgical checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491–9.

    Article  CAS  PubMed  Google Scholar 

  2. de Vries EN, Dijkstra L, Smorenburg SM, Meijer RP, Boermeester MA. The SURgical PAtient Safety System (SURPASS) checklist optimizes timing of antibiotic prophylaxis. Patient Saf Surg. 2010;4:6.

    PubMed Central  PubMed  Google Scholar 

  3. Ram K, Boermeester MA. Surgical safety. Br J Surg. 2013;100:1257–9.

    CAS  PubMed  Google Scholar 

  4. Norton E. Implementing the universal protocol hospital-wide. AORN J. 2007;85:1187–97.

    PubMed  Google Scholar 

  5. Stahel PF. Lessons learned from wrong-site, wrong-patient surgery. Phys Week. 2011;28(11).

    Google Scholar 

  6. Sparks EA, Wehbe-Janek H, Johnson RL, Smythe WR, Papaconstantinou HT. Surgical safety checklist compliance: a job done poorly! J Am Coll Surg. 2013;217:867–73.

    PubMed  Google Scholar 

  7. Hannam JA, Glass L, Kwon J, Windsor J, Stapelberg F, et al. A prospective, observational study of the effects of implementation strategy on compliance with a surgical safety checklist. BMJ Qual Saf. 2013;22:940–7.

    CAS  PubMed  Google Scholar 

  8. O’Connor P, Reddin C, O’Sullivan M, O’Duffy F, Keogh I. Surgical checklists: the human factor. Patient Saf Surg. 2013;7:14.

    PubMed Central  PubMed  Google Scholar 

  9. Clarke JR, Johnston J, Blanco M, Martindell DP. Wrong-site surgery: can we prevent it? Adv Surg. 2008;42:13–31.

    PubMed  Google Scholar 

  10. Stahel PF, Sabel AL, Victoroff MS, Varnell J, Lembitz A, et al. Wrong site and wrong patient procedures in the era of the Universal Protocol – analysis of a prospective database of physician self-reported occurrences. Arch Surg. 2010;145:78–84.

    Google Scholar 

  11. Wrong site surgery and the Universal Protocol. Bull Am Coll Surg. 2006;91:63.

    Google Scholar 

  12. Clarke JR, Johnston J, Finley ED. Getting surgery right. Ann Surg. 2007;246:395–403.

    PubMed Central  PubMed  Google Scholar 

  13. Dillon KA. Time out: an analysis. AORN J. 2008;88:437–42.

    PubMed  Google Scholar 

  14. Edwards P. Ensuring correct site surgery. J Perioper Pract. 2008;18:168–71.

    PubMed  Google Scholar 

  15. Hunter JG. Extend the universal protocol, not just the surgical time out. J Am Coll Surg. 2007;205:e4–5.

    PubMed  Google Scholar 

  16. Lembitz A, Clarke TJ. Clarifying ‘never events’ and introducing ‘always events’. Patient Saf Surg. 2009;3:26.

    PubMed Central  PubMed  Google Scholar 

  17. Catalano K. Have you heard? The saga of wrong site surgery continues. Plast Surg Nurs. 2008;28:41–4.

    PubMed  Google Scholar 

  18. Shinde S, Carter JA. Wrong site neurosurgery – still a problem. Anaesthesia. 2009;64:1–2.

    CAS  PubMed  Google Scholar 

  19. van Hille PT. Patient safety with particular reference to wrong site surgery – a presidential commentary. Br J Neurosurg. 2009;23:109–10.

    PubMed  Google Scholar 

  20. Wong DA, Herndon JH, Canale ST, Brooks RL, Hunt TR, et al. Medical errors in orthopaedics – results of an AAOS member survey. J Bone Joint Surg Am. 2009;91:547–57.

    PubMed  Google Scholar 

  21. Lindley EM, Botolin S, Burger EL, Patel VV. Unusual spine anatomy contributing to wrong level spine surgery: a case report and recommendations for decreasing the risk of preventable ‘never events’. Patient Saf Surg. 2011;5:33.

    PubMed Central  PubMed  Google Scholar 

  22. Jhawar BS, Mitsis D, Duggal N. Wrong-sided and wrong-level neurosurgery: a national survey. J Neurosurg Spine. 2007;7:467–72.

    PubMed  Google Scholar 

  23. Seiden SC, Barach P. Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable? Arch Surg. 2006;141:931–9.

    PubMed  Google Scholar 

  24. Stahel PF, Mehler PS, Clarke TJ, Varnell J. The 5th anniversary of the “Universal Protocol”: pitfalls and pearls revisited. Patient Saf Surg. 2009;3:14.

    PubMed Central  PubMed  Google Scholar 

  25. Altpeter T, Luckhardt K, Lewis JN, Harken AH, Polk Jr HC. Expanded surgical time out: a key to real-time data collection and quality improvement. J Am Coll Surg. 2007;204:527–32.

    PubMed  Google Scholar 

  26. Mitchell P, Nicholson CL, Jenkins A. Side errors in neurosurgery. Acta Neurochir (Wien). 2006;148:1289–92.

    CAS  Google Scholar 

  27. Cronen G, Ringus V, Sigle G, Ryu J. Sterility of surgical site marking. J Bone Joint Surg Am. 2005;87:2193–5.

    PubMed  Google Scholar 

  28. Cullan DB, Wongworawat MD. Sterility of the surgical site marking between the ink and the epidermis. J Am Coll Surg. 2007;205:319–21.

    PubMed  Google Scholar 

  29. Rooney J, Khoo OK, Higgs AR, Small TJ, Bell S. Surgical site marking does not affect sterility. ANZ J Surg. 2008;78:688–9.

    PubMed  Google Scholar 

  30. Zhao X, Chen J, Fang XQ, Fan SW. Surgical site marking will not affect sterility of the surgical field. Med Hypotheses. 2009;73:319–20.

    PubMed  Google Scholar 

  31. Stahel PF. The tenth year of the “Universal Protocol”: are our patients safer today? Bone Joint360. 2014;3:7–10.

    Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Orthopaedics, Denver Health Medical Center, University of Colorado, School of Medicine, 777 Bannock Street, MC 0188, Denver, CO, 80204, USA

    Philip F. Stahel MD, FACS

Authors
  1. Philip F. Stahel MD, FACS
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Corresponding author

Correspondence to Philip F. Stahel MD, FACS .

Editor information

Editors and Affiliations

  1. Department of Orthopaedics, Denver Health Medical Center, Denver, Colorado, USA

    Philip F. Stahel

  2. Department of Orthopaedics, Denver Health Medical Center, Denver, Colorado, USA

    Cyril Mauffrey

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© 2014 Springer-Verlag London

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Stahel, P.F. (2014). The Universal Protocol: Pitfalls and Pearls. In: Stahel, P., Mauffrey, C. (eds) Patient Safety in Surgery. Springer, London. https://doi.org/10.1007/978-1-4471-4369-7_14

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  • DOI: https://doi.org/10.1007/978-1-4471-4369-7_14

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  • Publisher Name: Springer, London

  • Print ISBN: 978-1-4471-4368-0

  • Online ISBN: 978-1-4471-4369-7

  • eBook Packages: MedicineMedicine (R0)

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