Joint Commission Works to Prevent Wrong Site Surgery

The Joint Commission Board of Commissioners originally approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery^TM in July 2003, and it became effective July 1, 2004 for all accredited hospitals, ambulatory care and office-based surgery facilities. The Universal Protocol was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery in Joint Commission accredited organizations. The Universal Protocol drew upon, and expanded and integrated, a series of requirements under The Joint Commission's 2003 and 2004 National Patient Safety Goals. There are three principal components of the Universal Protocol: conducting a preprocedure verification process, marking the procedure site, and performing a time-out before the procedure.

back to top