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Universal Protocol: Clarifying the physician’s role

Accreditation Connection, March 13, 2008

Q: According to the Universal Protocol for preventing wrong-site surgery, who is required to do the site marking? We are hearing that The Joint Commission states it must be the surgeon.

A: In the Universal Protocol, Requirement 1B, EP 6, it states that the person performing the procedure "should" do the site marking. A subtle shift in defining the word "should" was noted in 2007 in reviewing hospital requirements for improvement and clarification responses.

As of early February, The Joint Commission (formerly JCAHO) had not yet published its 2008 National Patient Safety Goal FAQs, but the rumors from this year's surveyor conference indicate that the term "should" has been somewhat redefined. What I hear is that the term means that the person performing the procedure should do the marking, unless there is some reason why he or she cannot. Many hospitals have interpreted the word using a Webster's-like definition in the belief that it gave them a choice as to whether the person performing the procedure had to be involved in site marking. These hospitals then established internal procedures, for the most part assigning site marking to nursing staff members.

Access the full story in the March issue of Briefings on The Joint Commission. Access is free for BOJ subscribers; nonsubscribers can purchase a copy of the story for $10 by clicking here.

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