What Is the Basis of the Universal Protocol?

Posted on April 17, 2025 writen by Jane Paulson in Medical Malpractice

Preventing medical errors is a top priority for healthcare systems worldwide. Surgical mistakes—such as wrong site, wrong procedure, or wrong patient surgeries—can lead to severe physical harm, emotional trauma, and long-term medical complications for patients and their families. Healthcare providers implement strict safety measures like the Universal Protocol to reduce these risks.

But what is the basis of the Universal Protocol, and how does it shape modern medical practice? This blog will explore its origins, applications, and importance in preventing surgical errors. We’ll also discuss what steps to take if you or a loved one has been a victim of medical negligence and how Paulson Coletti can help you.

The Origins and Importance of the Universal Protocol

The Universal Protocol was established in 2004 by the Joint Commission to prevent surgical errors. An AHRQ-supported study found that wrong-site surgery occurred in about 1 per 113,000 operations between 1985 and 2004, prompting the need for a standardized safety framework. Developed through expert consensus, the protocol addresses three major errors: wrong site, wrong procedure, and wrong person surgeries.

It applies to all accredited hospitals, ambulatory care centers, and office-based surgical facilities. A key requirement is the “time-out” before surgery, where the team reviews critical details to ensure the correct procedure is performed on the right patient and site.

This measure has improved teamwork and reduced errors, making it essential in modern medicine. These surgical mistakes are now classified as “never events” by the National Quality Forum, emphasizing their severity. Since 2009, the Centers for Medicare and Medicaid Services have refused to reimburse costs associated with these errors (AHRQ). Ultimately, what is the basis of the Universal Protocol? It is the commitment to eliminating surgical errors, enhancing patient safety, and promoting accountability.

How the Universal Protocol Helps Prevent Medical Errors

Pre-Procedure Verification

Before the procedure begins, the healthcare team must cross-check all relevant documents, such as patient charts, test results, and consent forms, to ensure they align with the medical plan.

Marking the Surgery Site

Whenever possible, the exact site for surgery must be marked with the patient’s involvement. This step is crucial for surgeries involving symmetrical body parts like hands or feet.

Conducting the Time-Out

The entire surgical team must pause and verbally confirm critical details, such as patient identity, correct surgical site, and procedure.

This step ensures clear communication among the surgical team, reducing errors caused by miscommunication. The Universal Protocol helps medical professionals operate with clarity and precision, significantly lowering the risk of mistakes.

Legal Implications of Failing to Follow the Universal Protocol

Ignoring the Universal Protocol can have serious legal and professional consequences. If negligence results in a surgical error, hospitals and medical professionals may face malpractice claims.

Victims can sue for damages, including pain, emotional distress, lost income, and medical costs. When safety standards are ignored, many malpractice cases have led to multi-million dollar settlements. Such violations also cause reputational harm and legal penalties.

Failure to follow the protocol can result in disciplinary actions, including license suspension or revocation. Medical boards are increasing oversight, recognizing that these preventable errors are unacceptable. Adhering to the protocol is both a legal and ethical duty.

What to Do If You Are a Victim of a Medical Error

Suffering from a medical error is a challenging and stressful experience, but there are steps you can take to protect yourself and pursue justice. According to the Oregon Patient Safety Commission, here are some actions to consider:

1. Seek Immediate Medical Attention: If the error has caused immediate health issues, prioritize getting medical help. Consider a second opinion to understand the harm and your options better. Early intervention can minimize long-term damage caused by medical errors.
2. Document Everything: Keep detailed notes about what happened, including dates, conversations, and the names of people involved. Obtain and review your medical records for accuracy. Documentation is one of the strongest forms of evidence in a malpractice case.
3. Talk to Someone You Trust: Communicate with a trusted healthcare professional or patient advocate. Many healthcare organizations have ombudsmen or advocates dedicated to assisting patients with complaints.
4. Consider Legal Action: If the error has caused significant harm, consult an experienced medical malpractice lawyer to understand your rights and evaluate your options. 

Contact Paulson Coletti for Legal Guidance on Medical Negligence

At Paulson Coletti, we understand the devastating impact medical errors can have on patients and their families. While safety measures like the Universal Protocol are designed to prevent surgical mistakes, errors still occur. But what is the basis of the Universal Protocol, and how does it protect patients? When these safeguards fail, victims deserve justice.

Our firm has secured major settlements, including a $3.55 million settlement for a surgical error. Call 503-682-8721 for a consultation.