What Steps Are Surgeons Required to Follow?

Surgery is an intimidating experience, whether it is something minimally invasive and planned or highly invasive and emergent. Most of us have heard horror stories of someone who goes into surgery for one thing and comes out having endured an entirely different kind of procedure. This kind of mistake may be medical malpractice due to the implementation of the Universal Protocol. If you have encountered this experience, it can be beneficial to consult a Portland medical malpractice lawyer with Paulson Coletti Trial Attorneys PC.

What Is Universal Protocol?

The Universal Protocol was implemented in 2004 in response to the high prevalence of wrong site, wrong patient, and wrong surgery errors in hospitals across the country. The protocol guidelines can be found on the Joint Commission website, and the following are the standards by which all surgical procedures should be verified.

Pre-procedure Verification

Before the procedure begins, the team should confirm that the correct patient, with the correct procedure, is on the correct site. The team should also include the patient in this process whenever possible. The surgical team should also take this time to confirm that all necessary materials are present, including the patient’s history, any imaging, and other medical documentation.

Mark the Procedure Site

The procedure site must be marked, at a minimum, when there is more than one possible site for the procedure or when performing the procedure in a different location, which could bring harm to the patient. The guidelines specify that the mark must be appropriately permanent to remain visible when the skin is cleaned and draped. Adhesive markings are not allowed as the primary form of indication. Additionally, the mark should be standardized in the hospital. There are some exceptions to this requirement for cases where it is not possible, such as teeth or specific internal structures.

The mark should be made by an independently licensed provider responsible for the surgery. Sometimes, the surgical site marking may be delegated to a resident or advanced practice registered nurse. Even if the mark is delegated, the

Time Out

Immediately prior to making the incision or beginning the procedure, the entire surgical team should discuss the patient’s details, including any relevant medical history or questions, and verbally confirm the surgery to be performed and the procedure site. The entire surgical team should be present for the time out, including the surgeon performing the procedure, surgical technicians, nursing staff, anesthesiologists, and anyone else who will be present. Everyone at the time out should actively communicate and document the time out. If the patient requires more than one procedure and the surgical provider changes, the team should complete an additional time out for the new procedure.

The universal protocol addressed a problem that was causing significant harm to surgical patients. As of 2006, the prevalence of these surgical errors had diminished so significantly that the National Quality Forum considers wrong site, wrong patient, and wrong surgery errors to be never events, meaning they are so rare they are shocking when they occur. Regardless of the policies in place, medical professionals will always have moments of negligence that cause harm. If this happens to you, you have legal recourse.