Joint Commission Updates Universal Protocol

Written by Staff | February 17, 2010

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The Joint Commission has revised its Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery to clarify a site marking rule, according to a release by The Joint Commission.

The Joint Commission is updating the note to UP.01.02.01, EP 5, to make it clear that site marking is not required for interventional procedures for which the catheter/instrument insertion site is not predetermined, such as cardiac catheterization and pacemaker insertion, according to the report.

The protocol has previously stated that site marking alternatives were necessary for these procedures, but recently determined that the statement conflicted "with an existing interpretation indicating that site marking is not required when insertion sites are not predetermined," according to the release.

This change affects ambulatory care organizations, critical access hospitals, hospitals and office-based surgery practices, according to the release.

Read the release on the Joint Commission's updated Universal Protocol (pdf).