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From Patient Safety Officer Deborah Riley, M.D., and Tracey A. Ross, Ed. D., CST, Manager of Patient Safety, Quality & Education, Perioperative Services
The Universal Protocol was developed to prevent wrong person, wrong procedure and wrong site surgery in healthcare facilities.
The three components of the Universal Protocol are:

  1. Patient identification and pre-procedure verification

  2. Site marking (as applicable and per policy)

  3. The Time Out Process

Errors continue to occur across the nation despite many focused efforts on Universal Protocol and the Time Out Process. Root causes of the identified errors are linked to communication and/or teamwork breakdowns, incorrect information in the patient’s medical record, patient and procedural factors, deviations from established policies and failed safety systems.
Consistent implementation of a standardized protocol is most effective in achieving patient safety. At Lancaster General Health/Penn Medicine, all teams and providers must follow their unit-specific Universal Protocol/Time Out Policy or the global LG Health Universal Protocol Policy located in the Metric Stream Policy System. Each policy specifically addresses the three key components of the Universal Protocol.
At each verification point within the Universal Protocol, all team members must be in full agreement to proceed. If for any reason a member of the team has a concern or a question, he or she must “Stop the Line.” The team does not proceed until all parties agree on the Universal Protocol or Time Out elements that are in question.  
If you have questions regarding this announcement or any other issues related to Patient Safety, please contact the Patient Safety Office, 544-1016, or leave a suggestion or other concern 24/7 on the voicemail of the Patient Safety First Line, 544-4040.

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