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PRACTICAL INNOVATIONS
Using an Alternative Site Marking Form to Comply With the Universal Protocol
ELIZABETH NORTON, BSN, RN, CNOR
The intent of the Joint Commissions Universal Protocol is to prevent wrong site, wrong procedure, and wrong person sur
gery. The Universal Protocol went into effect as a National Patient Safety Goal in 2004.1 Over time, requirements for the Universal Protocol have evolved with the intent to decrease the incidence and severity of adverse events, including sentinel events.2 The Joint Commission has been collecting voluntary data on sentinel events since 1996. Despite widespread media attention and efforts by professional organizations and regulatory bodies, wrong patient, wrong site, and wrong procedure events were on the rise through 20093 (Figure 1).
The three major components of the Universal Protocol include conducting a preprocedure verication, marking the procedure site, and performing a time out before the procedure. The site tobe marked is often clear (eg, right leg versus left leg), and patients typically accept a facilitys site-marking procedures. However, certain procedures are performed in areas of the body that are dif-cult or impossible to mark (eg, mucosal surfaces, internal organs, the perineum), on patients who cannot be marked (eg, premature infants), or on patients who object to or refuse marking. Organizations are responsible for having a written plan in place for patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site. At Childrens Hospital Boston (CHB), the OR patient safety and
quality nurse developed a form for alternative site marking. This new form meets the Joint Commissions intent and was approved by the CHB OR governance committee. This form is available to other facilities in which personnel are developing their own plans for alternative site marking.
BACKGROUND
Before 2004, many institutions had already implemented site marking and a time out to prevent wrong site sentinel events. Despite previous recommendations from the Joint Commission for site marking, as well as written policies and good intentions, perioperative personnel expressed that they were meeting resistance as they attempted to enforce these practice changes. To reduce resistance as well as improve communication among team members and offer some exibility for unique surgical situations, the Joint Commission established the Universal Protocol with the over-arching goal...