Is The Universal Protocol Working?

Millions of people require life saving procedures each year in the United States. When going in for surgery, it is a given that someone in the operating room is going to make a wisecrack about writing “operate here” on the patient. 

But wrong site, wrong side surgery is no joke, as wrong-site surgeries occur between 1,300 and 2,700 times a year in the United States. This equates to physicians still performing surgery on the wrong part of the body, performing the wrong procedure, or operating on the wrong patient altogether roughly 40 times a week. 

What is the universal protocol and who created it?

The Universal Protocol dictates the minimum requirements physicians must follow to help prevent basic surgical mistakes and is required to be implemented by all accredited hospitals, ambulatory care, and office-based surgical facilities.

In 2004, The Joint Commission released the Universal Protocol. As a result, the initial seven hospitals involved in rolling out the protocol reduced the number of surgical cases with risks for wrong-site surgery by 46 percent in the scheduling area, 63 percent in the pre-op/holding area, and 51 percent in the operating room. These numbers translate to thousands of people being spared from having dangerous procedures done on the wrong parts of their bodies. 

Despite having an effective universal protocol, not all hospitals abide by it, making preventable mistakes even more egregious.

What are the steps a surgeon must follow?

The Universal Protocol is a checklist a surgeon must go through with their surgical team before beginning to operate. The three steps a surgeon must follow before beginning a procedure are:

Conduct a pre-procedure verification process

This process includes verification of the correct surgery and site, as well as verifying the identity of the patient and making sure all necessary tools are available. Simply put, the surgeon, along with all healthcare professionals present during the procedure, must address missing information or discrepancies before starting. 

Mark the procedure site

The protocol requires that at minimum, the surgeon must mark the site when there is more than one possible location for the procedure. The surgeon should clearly label the area where the surgery should be performed with a surgical marker. The surgeon should mark the line that the incision should follow as well as the word “yes.”

Perform a time-out

All participating members of the surgical team should be present during the time-out and the procedure cannot begin until all questions and concerns are resolved. The team must verbally agree that the patient is the correct patient, the correct procedure is going to be carried out, and that the surgery is going to be performed at the correct site.

3 of the worst surgical errors in the United States

The following examples are of the most egregious surgical errors and have garnered attention because each of them were considered 100 percent preventable. In each of these three cases, the vital information was readily available and at hand within the patient’s chart. 


  • Location: Rhode Island 
  • Case: Surgeons operate on the wrong side of three different patients’ heads 
  • Outcome: All three occurred in one year, two survived, one did not

Transplant Surgery

  • Location: Duke University Hospital
  • Case: Organs with the wrong blood type were transplanted
  • Outcome: Heart and Lungs were replaced, but patient did not survive


  • Location: University Community Hospital
  • Case: Wrong leg removed
  • Outcome: Ultimately, the patient lost both legs

Managing pre-op anxiety

It is practical to advocate for yourself and find out what your surgeon is doing to prevent wrong side, wrong site procedures by asking if they follow the Universal Protocol.

Every patient who goes in for surgery likely has anxiety surrounding their procedure no matter how invasive it may be. Prior to any surgical procedure, the patient should meet several members of the surgical team and have ample time to ask questions. Confirming name, birth date and procedure should be done in every interaction without exception.

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