Table 8. Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) Universal Protocol

UP.01.01.01: Conduct a pre-procedure verification process

    Ensure that all relevant documents and information or equipment are:

        -Available before starting procedure

        -Correctly identified, labeled, and matched to patient’s identifiers

        -Reviewed and are consistent with patient’s expectations and team’s understanding of intended

         patient, procedure and site

UP.01.02.01: Mark the procedure site

        -Mark at or near procedure or incision site

        -Preferably include proceduralist’s initials, with or without a line representing the proposed 


        -Use permanent marker that remains visible after completion of skin prep and sterile draping

        -Position marking to be visible after skin prep, patient positioning and sterile draping are completed

UP.01.03.01: Perform a time-out immediately prior to starting procedures

        -Addressing correct patient identity, correct side and site, accurate procedure consent form and

         procedure, correct patient position, relevant images and results are properly labeled and

         appropriately displayed, safety precautions based on patient history or medication use, need to

         administer antibiotics or fluids for irrigation purposes

Adapted from Joint Commission on the Accreditation of Healthcare Organizations [93,94].