Joint Commission Updates Universal Protocol

The Joint Commission is revising its Universal Protocol for Preventing Wrong site, Wrong Procedure, Wrong Person Surgery™ (UP) to clarify a site marking rule. While the protocol has previously stated that site marking alternatives are necessary in “interventional procedure cases for which the catheter/instrument insertion site is not predetermined (for example, cardiac catheterization, pacemaker insertion),” the commission says, “That statement conflicts with an existing interpretation indicating that site marking is not required when insertion sites are not predetermined.”

The commission is updating the note to UP.01.02.01, EP 5, to make it clear that site marking is not required for such procedures. This change affects ambulatory care organizations, critical access hospitals, hospitals, and office-based surgery practices.

Source: Outpatient Surgery Magazine (Feb. 2 e-weekly edition)


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