The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited.

Philip F. Stahel; Philip S. Mehler; Ted J. Clarke; Jeffrey Varnell

Commentary

The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited.

July 29, 2009

Stahel PF, Mehler PS, Clarke TJ, et al. Patient Saf Surg. 2009;3(1):14.

View more articles from the same authors.

Five years after the publication of the Universal Protocol, the authors review the policy and assess unintended consequences, limitations, and recommendations to reduce surgical errors.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.

October 27, 2010

Disclosure and reporting of surgical complications: a double-edged sword?

August 18, 2010

Current challenges and future perspectives for patient safety in surgery.

March 12, 2014

Clinical triggers: an alternative to a rapid response team.

March 4, 2009

Vital sign abnormalities, rapid response, and adverse outcomes in hospitalized patients.

January 30, 2013

Medication errors with the use of allopurinol and colchicine: a retrospective study of a national, anonymous Internet-accessible error reporting system.

March 8, 2006

To tell the truth, the whole truth, may do patients harm: the problem of the nocebo effect for informed consent.

May 16, 2012

Safe use of cellular telephones in hospitals: fundamental principles and case studies.

November 16, 2005

Parent participation in morbidity and mortality review: parent and physician perspectives.

June 22, 2022

Computer based medication error reporting: insights and implications.

June 21, 2006

Applying modern error theory to the problem of missed injuries in trauma.

April 2, 2008

Increasing patient safety and efficiency in transfusion therapy using formal process definitions.

January 10, 2007

Minimizing errors of omission: Behavioural rEenforcement of Heparin to Avert Venous Emboli: The BEHAVE Study.

March 8, 2006

Strategies for preventing distractions and interruptions in the OR.

June 19, 2013

The role for leaders of health care organizations in patient safety.

September 19, 2007

The impact of technology on safe medicines use and pharmacy practice in the US.

January 30, 2019

Resident supervision and patient safety: do different levels of resident supervision affect the rate of morbidity and mortality cases?

August 26, 2015

A patient safety checklist for the cardiac catheterisation laboratory.

January 7, 2015

Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room.

June 4, 2014

A surgical procedure grid for safety and operating room communication in multisite surgery.

January 31, 2018

A prospective, observational study of the effects of implementation strategy on compliance with a surgical safety checklist.

October 30, 2013

Interunit handoffs from emergency department to inpatient care: a cross-sectional survey of physicians at a university medical center.

August 5, 2015

User-centered collaborative design and development of an inpatient safety dashboard.

September 20, 2017

Improving oversight of the graduate medical education enterprise: one institution's strategies and tools.

May 10, 2006

Comparison of computerized surveillance and manual chart review for adverse events.

June 29, 2011

Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality.

March 27, 2005

Involving users in the design of a system for sharing lessons from adverse incidents in anaesthesia.

April 5, 2006

Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction.

April 3, 2005

Improving patient safety: the comparative views of patient-safety specialists, workforce staff and managers.

January 30, 2005

Secure text messaging in healthcare: latent threats and opportunities to improve patient safety.

October 30, 2019

Internally-developed online adverse drug reaction and medication error reporting systems.

June 7, 2006

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2017.

October 31, 2018

ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education—2015.

September 14, 2016

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2014.

August 12, 2015

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2010.

June 6, 2012

ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education—2009.

June 13, 2012

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2011.

May 9, 2012

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2016.

September 20, 2017

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2013.

July 23, 2014

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2008.

May 20, 2009

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2007.

June 4, 2008

Weight and size descriptors for drug dosing: too many options and too many errors.

January 11, 2023

Educational levels of hospital nurses and surgical patient mortality.

April 3, 2005

Advancing the future of patient safety in oncology: implications of patient safety education on cancer care delivery.

June 10, 2015

Patient safety in the office-based setting.

April 19, 2006

Effect of bar-code–assisted medication administration on medication error rates in an adult medical intensive care unit.

June 24, 2009

Second victims need emotional support after adverse events: even in a just safety culture.

April 3, 2019

Adoption of health information technology for medication safety in US hospitals, 2006.

May 28, 2008

Mandatory reporting of impaired medical practitioners: protecting patients, supporting practitioners.

February 4, 2015

Family-centered rounds on pediatric wards: a PRIS network survey of US and Canadian hospitalists.

July 14, 2010

Oncology medication safety: a 3D status report 2008.

November 5, 2008

Improving the accuracy of patient identification in the medication-use process.

February 8, 2006

Building a safety culture.

December 21, 2005

Impact of resident workload and handoff training on patient outcomes.

April 4, 2012

Health information technology and patient safety: evidence from panel data.

March 25, 2009

Clinical perspective: creating an effective practice peer review process—a primer.

March 29, 2017

An intervention model that promotes accountability: peer messengers and patient/family complaints.

October 9, 2013

Utility of an online medication-error-reporting system.

November 23, 2005

Interrater agreement with a standard scheme for classifying medication errors.

January 24, 2007

Medication errors and patient complications with continuous renal replacement therapy.

May 3, 2006

Surgical simulation: a systematic review.

March 8, 2006

Evaluation of laboratory monitoring alerts within a computerized physician order entry system for medication orders.

September 20, 2006

ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education—2018.

August 21, 2019

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing-2019.

September 30, 2020

ASHP National Survey of Pharmacy Practice in Hospital Settings: clinical services and workforce-2021.

October 19, 2022

Customer focused incident monitoring in anaesthesia.

June 6, 2007

Enhancing medication use safety: benefits of learning from your peers.

October 21, 2009

Safety leadership: a meta-analytic review of transformational and transactional leadership styles as antecedents of safety behaviours.

April 24, 2013

Trends influencing the cost of care and patient safety.

July 26, 2006

The Quality and Safety Educators Academy: fulfilling an unmet need for faculty development.

May 22, 2013

What became of the 'eyes and the ears'?: exploring the challenges to reporting poor quality of care among trainee medical staff.

August 11, 2021

Machine learning in medicine.

April 10, 2019

A study of the frequency and rationale for overriding allergy warnings in a computerized prescriber order entry system.

June 20, 2007

Exploring the role of salient distracting clinical features in the emergence of diagnostic errors and the mechanisms through which reflection counteracts mistakes.

March 21, 2012

Undermining and bullying in surgical training: a review and recommendations by the Association of Surgeons in Training.

October 14, 2015

The effect of clinical experience on the error rate of emergency physicians.

December 3, 2008

Facilitation of surgical innovation: is it possible to speed the introduction of new technology while simultaneously improving patient safety?

April 24, 2019

A simulation design for research evaluating safety innovations in anaesthesia.

January 28, 2009

Positive predictive value of the AHRQ accidental puncture or laceration patient safety indicator.

January 20, 2010

Reduction in opioid prescribing through evidence-based prescribing guidelines.

December 20, 2017

A comprehensive obstetric patient safety program reduces liability claims and payments.

June 25, 2014

A prevalence study of errors in opioid prescribing in a large teaching hospital.

August 10, 2011

Implementing the Comprehensive Unit-Based Safety Program (CUSP) to improve patient safety in an academic primary care practice.

October 18, 2017

Medication safety pharmacy technician in a large, tertiary care, community hospital.

March 30, 2016

Adoption of technology to improve medication safety: perspectives of pharmacy directors.

January 10, 2007

Sleep deprivation: implications for obstetric practice in the United States.

August 26, 2009

Supporting nurses in acute and emergency care settings to speak up.

November 8, 2023

Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical analysis.

April 21, 2005

Standards for patient monitoring during general anesthesia at Harvard Medical School.

March 6, 2005

Unpredictable drug shortages: an ethical framework for short-term rationing in hospitals.

April 4, 2012

Zero preventable deaths after traumatic injury: an achievable goal.

July 12, 2017

Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients' safety: assessor-blind pilot comparison.

February 25, 2009

Colonoscopic withdrawal times and adenoma detection during screening colonoscopy.

January 10, 2007

Variations in surgical safety according to affiliation status with a top-ranked cancer hospital.

July 24, 2019

Bad stars or guiding lights? Learning from disasters to improve patient safety.

May 12, 2010

Emergency department medication lists are not accurate.

November 12, 2008

Unrealized potential and residual consequences of electronic prescribing on pharmacy workflow in the outpatient pharmacy.

July 9, 2014

Preliminary assessment of pediatric health care quality and patient safety in the United States using readily available administrative data.

August 13, 2008

A national profile of patient safety in U.S. hospitals.

March 6, 2005

Attitudes and practices related to clinical alarms.

June 11, 2014

Related Resources

Patient Safety Authority Annual Reports.

May 1, 2023

Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years.

February 8, 2023

National Safety Standards for Invasive Procedures (NatSSIPs2).

February 7, 2023

Interview

In Conversation with... Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS

December 14, 2022

Perspective

Resilient Healthcare and the Safety-I and Safety-II Frameworks

December 14, 2022

Preventing patient positioning injuries in the nonoperating room setting.

August 24, 2022

Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery.

September 22, 2021

Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the COVID-19 pandemic: a review.

May 12, 2021

Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a "Never Event".

August 5, 2020

Reduce the likelihood of patient harm associated with the use of anticoagulant therapy: commentary from the Anticoagulation Forum on the Updated Joint Commission NPSG.03.05.01 Elements of Performance

March 4, 2020

Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.

December 5, 2018

Evaluation of a patient safety programme on Surgical Safety Checklist compliance: a prospective longitudinal study.

August 15, 2018

Postoperative opioid prescribing: Getting it RIGHTT.

March 21, 2018

Back to basics: the Universal Protocol.

January 24, 2018

Global Guidelines on the Prevention of Surgical Site Infection.

January 3, 2018

Reduction of incorrect record accessing and charting patient electronic medical records in the perioperative environment.

February 15, 2017

WebM&M Cases

Getting the (Right) Doctor, Right Away

August 21, 2016

Guideline implementation: prevention of retained surgical items.

August 3, 2016

Advancing Patient Safety in Cataract Surgery: A Betsy Lehman Center Expert Panel Report.

June 15, 2016

WebM&M Cases

Fire in the Hole!—An OR Fire

April 1, 2015

WebM&M Cases

Two Wrongs Don't Make a Right (Kidney)

March 1, 2015

Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project.

October 8, 2014

Back to basics: preventing surgical site infections.

June 4, 2014

Standardise, Educate, Harmonise: Commissioning the Conditions for Safer Surgery.

April 23, 2014

Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association.

August 21, 2013

Measure twice, cut once.

July 24, 2013

Necessity of a good surgical history: detection of a gossypiboma.

July 17, 2013

Developing and pilot testing practical measures of preanalytic surgical specimen identification defects.

March 27, 2013

EACTS guidelines for the use of patient safety checklists.

March 29, 2012

Preoperative surgical briefings do not delay operating room start times and are popular with surgical team members.

September 7, 2011

See More About The Topic

Operating Room

Health Care Providers

Health Care Executives and Administrators

Surgery

Identification Errors

The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site