Universal Protocol in Healthcare

Posted on May 8, 2025 writen by Jane Paulson in Medical Malpractice

Understanding the universal protocol in healthcare is vital to recognizing how medical errors—especially surgical mistakes—can be prevented in both clinical and hospital settings. This nationally recognized safety measure outlines clear, standardized steps that medical professionals must follow to ensure patient safety before any invasive procedure. From confirming the correct patient and procedure to marking the surgical site and conducting a final time-out, the protocol creates a culture of accountability in the operating room. These steps are especially important in high-risk environments like surgical centers and trauma units, where a momentary lapse in communication can lead to devastating consequences. Across Portland, Oregon, patients trust their healthcare providers to adhere to these protocols without exception. If these standards are violated and harm occurs, a Portland medical malpractice lawyer from Paulson Coletti Trial Attorneys PC can help. We represent individuals harmed by medical negligence and surgical errors, ensuring they receive the advocacy and justice they rightfully deserve.

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What Is the Universal Protocol in Healthcare?

The universal protocol in healthcare is a nationwide safety standard developed to prevent surgical errors before invasive procedures. It applies to hospitals, outpatient clinics, and other healthcare facilities to ensure consistent patient safety practices.

This protocol was established to reduce critical mistakes, including:

• Performing surgery on the wrong patient
• Operating on the incorrect body site
• Executing the wrong procedure

According to the Association of periOperative Registered Nurses (AORN), adherence to the protocol has become standard across surgical specialties, serving as a non-negotiable process for every surgical team.

Why Was the Universal Protocol Created?

The universal protocol was introduced in response to a rise in preventable surgical mistakes that put patient lives at risk. In 2003, the Joint Commission and other medical leaders created the protocol to target communication failures and procedural oversights, which were identified as leading causes of wrong-site surgeries.

A publication in the Journal of Vascular and Interventional Radiology explains how miscommunication and poor surgical planning can escalate into irreversible patient harm. Since then, the Universal Protocol has become the foundation of surgical safety nationwide.

The Three Key Steps of the Universal Protocol

The protocol is structured around three core safety actions that every surgical team must follow. These steps help standardize procedures and create a culture of responsibility before any incision is made.

Pre-Procedure Verification Process

This step confirms all critical information before surgery begins. It includes verifying:

• The patient’s identity using two forms of identification
• The exact procedure to be performed
• The correct surgical site and side of the body
• Necessary equipment and diagnostic reports

By confirming these details early, healthcare professionals reduce the margin for error.

Marking the Surgical Site

This involves clearly marking the intended area of surgery while the patient is awake and involved. The person performing the procedure must mark the site using a permanent marker.

Key guidelines include:

• Using unambiguous markings (such as “YES”)
• Ensuring visibility after patient prepping and draping
• Involving the patient whenever possible for confirmation

This visible mark is a physical safeguard against wrong-site operations.

Conducting a Time-Out

A “time-out” is a final safety check that takes place in the operating room, immediately before surgery starts.

All team members must stop and verbally confirm:

• The correct patient
• The surgical procedure
• The marked site

The time-out fosters team communication and ensures everyone agrees before proceeding. It’s also the most direct way to prevent errors due to assumptions or miscommunication.

The Impact of Surgical Errors on Patients

Surgical mistakes can lead to long-term consequences for patients, including physical harm, psychological trauma, and financial hardship. When a medical professional fails to follow the Universal Protocol, the results can be catastrophic.

Common repercussions include:

• Permanent injury or disability
• Additional surgeries to correct the error
• Extended hospital stays and rehabilitation
• Emotional distress and loss of trust in the healthcare system

In Portland, these cases may qualify as medical malpractice, especially when standard protocols were ignored or misapplied.

Seeking Legal Help for Medical Negligence

When medical professionals fail to follow safety procedures like the Universal Protocol, they may be held liable for any resulting harm. If you or someone you love has suffered due to a surgical error, it’s critical to consult with an experienced medical malpractice attorney in Portland.

Protect Your Rights—Contact Our Portland Medical Malpractice Team

If you believe a failure to follow the universal protocol in healthcare caused your injury or a loved one’s, we are here to help. Our Portland-based legal team will thoroughly investigate your case and advocate aggressively on your behalf. Call Paulson Coletti Trial Attorneys PC today to schedule a free consultation and take the first step toward justice.