Universal Protocol Implementation

Posted on Oct 10, 2017 in Clinical Documentation | 0 comments

On behalf of Dr. Stephen Lockhart, MD, PhD, Chief Medical Officer, Sutter Health

Effective September 19, 2017, a new enhanced Universal Protocol was implemented in all Acute Care Hospitals and Ambulatory Surgery Centers that affect clinicians in surgical and non-surgical areas where invasive procedures are performed.

In 2016, an increased trend of wrong patient, wrong procedure, and wrong site events was identified within the Sutter system.  As a result, representatives from across the system came together to create a model process so that every patient will experience the same highly reliable process, every time, no matter where they undergo an invasive procedure in Sutter Health.

The Universal Protocol provides a process to ensure staff and providers catch potential errors before, during, and after the procedure. That way we ensure our patients receive the safest care.

We do many invasive procedures in non-surgical areas and the risk of having a ‘wrong’ event is as great in these locations. Therefore, these safety standards apply in all care areas where invasive procedures are performed. We understand that you and your team may have never experienced one of these events. The goal of the Universal Protocol is to ensure you never have to, because that pain is something no patient, no team, and no individual provider should have to endure.

Thank you for your support and active participation in these efforts to eliminate patient harm by incorporating these new expectations into your standard work.  Please note the following enhancements:

The Anesthesiologist signs the block site with the letter ‘B’ circled (see attachment for example)

  • The Anesthesiologist leads the team in the Sign-In
  • The Proceduralist marks the site in the pre-op area with their initials, or on body diagram
  • The Proceduralist leads the team in the Time-Out
  • The Registered Nurse leads the Sign-Out

With your support we can ensure that these ‘Wrong’ events become ‘Never’ events at Sutter Health and we can fulfill the trust our patients place in us when they select us to provide their care.

The below infographic highlights several key expectations incorporated into the new Universal Protocol 3 step process – Sign In; Time Out; Sign Out.  Please take a moment to review the highlighted areas on the attached document.






















Stephen Lockhart, MD, PhD
Chief Medical Officer, Sutter Health