Commentary Back to basics: the Universal Protocol. Citation Text: Spruce L. Back to Basics: The Universal Protocol: 1.4 www.aornjournal.org/content/cme. AORN J. 2018;107(1):116-125. doi:10.1002/aorn.12002. Copy Citation Format: DOIGoogle ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL January 24, 2018 Spruce L. AORN J. 2018;107(1):116-125. View more articles from the same authors. Wrong-site, wrong-procedure, and wrong-patient errors are surgical never events. This commentary describes a structured communication practice requirement designed to address the problem. The author outlines elements of the protocol and reviews implementation strategies. PubMed citation Available at Free full text (PDF) Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Spruce L. Back to Basics: The Universal Protocol: 1.4 www.aornjournal.org/content/cme. AORN J. 2018;107(1):116-125. doi:10.1002/aorn.12002. Copy Citation Format: DOIGoogle ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations. March 17, 2021 Back to basics: counting soft surgical goods. April 20, 2016 Back to basics: preventing surgical site infections. June 4, 2014 Medical-surgical nurse leaders' experiences with safety culture: an inductive qualitative descriptive study. November 9, 2022 A quality improvement initiative to improve pediatric discharge medication safety and efficiency. August 16, 2023 Preventing potential patient harm through clinical content interventions during oncology clinical trial implementation. 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We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations. March 17, 2021
Medical-surgical nurse leaders' experiences with safety culture: an inductive qualitative descriptive study. November 9, 2022
A quality improvement initiative to improve pediatric discharge medication safety and efficiency. August 16, 2023
Preventing potential patient harm through clinical content interventions during oncology clinical trial implementation. September 20, 2023
Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. October 24, 2018
Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients. January 14, 2015
Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team training. April 30, 2014
Using potentially preventable severe maternal morbidity to monitor hospital performance. February 8, 2023
Medication errors in community pharmacies: evaluation of a standardized safety program. March 15, 2023
Effect of Patient and Family Centered I-PASS on adverse event rates in hospitalized children with complex chronic conditions. March 8, 2023
Pediatric trainees' speaking up about unprofessional behavior and traditional patient safety threats. September 30, 2020
Does increased schedule flexibility lead to change? A national survey of program directors on 2017 work hours requirements. September 23, 2020
Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020
Patient perceptions of misdiagnosis of endometriosis: results from an online national survey. July 29, 2020
The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support. July 29, 2020
Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. May 12, 2021
Diagnostic accuracy of prehospital triage tools for identifying major trauma in elderly injured patients: a systematic review. May 5, 2021
Changes in error patterns in unanticipated trauma deaths during 20 years: in pursuit of zero preventable deaths. March 24, 2021
The development and piloting of the Ambulatory Electronic Health Record Evaluation Tool: lessons learned. March 17, 2021
Assessment of patients' ability to review electronic health record information to identify potential errors: cross-sectional web-based survey. March 10, 2021
Adverse events among emergency department patients with cardiovascular conditions: a multicenter study. March 10, 2021
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Transmission of community- and hospital-acquired SARS-CoV-2 in hospital settings in the UK: a cohort study. November 10, 2021
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Using failure mode and effects analysis to increase patient safety in cancer chemotherapy. December 22, 2021
Remember that patient you saw last week: characteristics and frequency of patients experiencing anticipated and unanticipated death following ED discharge. December 1, 2021
Provider bias in prescribing opioid analgesics: a study of electronic medical records at a hospital emergency department. September 8, 2021
Racial disparities in preventable adverse events attributed to poor care coordination reported in a national study of older US adults. September 1, 2021
Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect? August 25, 2021
Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting. August 18, 2021
Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial. August 18, 2021
Use of a structured approach and virtual simulation practice to improve diagnostic reasoning. February 23, 2022
Why is safety in intrapartum electronic fetal monitoring so hard? A qualitative study combining human factors/ergonomics and social science analysis. February 7, 2024
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Gender bias in risk management reports involving physicians in training - a retrospective qualitative study. November 9, 2022
‘I am not the doctor for you’: physicians’ attitudes about caring for people with disabilities. October 26, 2022
Testimonial injustice: linguistic bias in the medical records of black patients and women. June 6, 2021
Evaluation of medication incidents in a long-term care facility using electronic medication administration records and barcode technology. October 5, 2022
Spreading a strategy to prevent suicide after psychiatric hospitalization: results of a quality improvement spread initiative. October 5, 2022
Residents, responsibility, and error: how residents learn to navigate the intersection. August 16, 2023
Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. July 19, 2023
Acute clinical deterioration and consumer escalation: the understanding and perceptions of hospital staff. August 31, 2022
Quality measures for patients at risk of adverse outcomes in the Veterans Health Administration: expert panel recommendations. August 17, 2022
Patients' willingness and ability to identify and respond to errors in their personal health records: mixed methods analysis of cross-sectional survey data. July 27, 2022
Learning from latent safety threats identified during simulation to improve patient safety. October 11, 2023
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Changes in medication safety indicators in England throughout the covid-19 pandemic using OpenSAFELY: population based, retrospective cohort study of 57 million patients using federated analytics. June 7, 2023
Effect of an emergency department process improvement package on suicide prevention: the ED-SAFE 2 cluster randomized clinical trial. May 31, 2023
Changes to primary care delivery during the COVID-19 pandemic and perceived impact on medication safety: a survey study. June 29, 2022
Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. June 22, 2022
In situ simulation for adoption of new technology to improve sepsis care in rural emergency departments. June 22, 2022
Analysis of hospital-level readmission rates and variation in adverse events among patients with pneumonia in the United States. June 22, 2022
From principles to practice: embedding clinical reasoning as a longitudinal curriculum theme in a medical school programme. June 15, 2022
Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement. June 1, 2022
A learning health system agenda for organizational approaches to enhancing occupational well-being among clinicians. May 25, 2022
Impact of providing patients access to electronic health records on quality and safety of care: a systematic review and meta-analysis. July 8, 2020
An integrative total worker health framework for keeping workers safe and healthy during the COVID-19 pandemic. July 1, 2020
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National trends in the safety performance of electronic health record systems from 2009 to 2018. June 17, 2020
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Assessing content validity and user perspectives on the Team Check-up Tool: expert survey and user focus groups. April 5, 2017
From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system. March 1, 2017
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A multilevel analysis of U.S. hospital patient safety culture relationships with perceptions of voluntary event reporting. November 30, 2016
Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases and complaints in Canada. April 3, 2024
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Intraoperative communications between pathologists and surgeons: do we understand each other? September 6, 2023
Understanding ultrarare adverse events - lessons learned from a twelve-year review of intraoperative deaths at an academic medical center. June 21, 2023
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WebM&M Cases Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. December 14, 2022
WebM&M Cases False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. October 27, 2022
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WebM&M Cases Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest January 26, 2022
WebM&M Cases Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected August 25, 2021
System factors affecting intraoperative risk and resilience: applying a novel integrated approach to study surgical performance and patient safety. February 10, 2021
Adaptive design: adaptation and adoption of patient safety practices in daily routines, a multi-site study. August 12, 2020
Use of error management theory to quantify and characterize residents' error recovery strategies. January 15, 2020
Lack of association between intraoperative handoff of care and postoperative complications: a retrospective observational study. November 6, 2019
Use of a public health law framework to improve medication safety by anesthesia providers. March 20, 2019