Improving Patient Safety During Bedside Procedures: Successfully Implementing the Universal Protocol

1Northwestern University Feinberg School of Medicine, Chicago, IL
2Northwestern Memorial Hospital, Chicago, IL

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 18


The Universal Protocol was created by the Joint Commission to eliminate the occurrence of wrong‐site, wrong‐procedure, and wrong‐person surgery. This study evaluated the effects of an innovative reengineered process for bedside procedures with an aim of improving compliance with the Universal Protocol (specifically, time‐out) and increasing nursing and physician communication during bedside procedures.


This pre‐/postintervention study of implementation of the Universal Protocol for bedside procedures at a large tertiary‐care academic medical center was undertaken from July 2008 to May 2010. Administrative data identified patients who underwent lumbar puncture, paracentesis, or thoracentesis on inpatient medicine units. Compliance with time‐out was compared from baseline (10 months before) to postintervention (9 months after). Pre‐ and postintervention surveys were sent to clinicians addressing their experience, bedside procedure participation, and time‐out compliance. The postintervention survey also evaluated physician–nurse communication, patient safety, and utilization of the new process. The primary outcome measure was the rate of documented timeout compliance before and after implementation of the intervention. Secondary outcomes were clinician perceptions of compliance and safety before and after the intervention.


A total of 265 procedures performed at the bedside on medical floors qualified for study inclusion. Preintervention, 16% of procedures had a documented time‐out compared with 94% of postintervention procedures (OR, 83.5; 95% CI, 31.8–219.5). Survey results indicated that preintervention, only 59% of the nursing staff who participated in a bedside procedure (23 of 39) assisted in a pre‐procedure time‐out compared with 96% (56 of 58; OR, 19.5; 95% CI, 4.1–91.6) postintervention. Physicians reported 33% (19 of 57) compliance preintervention and 87% (33 of 38) postintervention (OR, 13.2; 95% CI, 4.4–39.3). In the postintervention survey 78% of nurses (62 of 80) felt the intervention improved their involvement in patient care, 67% (54 of 81) felt it improved nurse–physician communication, and 74% (61 of 82) felt it improved patient safety. Physicians did not agree with nurses that the intervention improved communication (47%; 34 of 72; P = 0.016) or patient safety (38%; 27 of 71; P < 0.001).


A hospital‐based intervention using a well‐engineered process integrated with the electronic medical record enhances patient safety by increasing compliance with the Universal Protocol.


J. H. Barsuk ‐ none; H. Brake ‐ none; T. Caprio ‐ none; C. Barnard ‐ none; D. Anderson ‐ none; M. Williams ‐ none

To cite this abstract:

Barsuk J, Brake H, Caprio T, Barnard C, Anderson D, Williams M. Improving Patient Safety During Bedside Procedures: Successfully Implementing the Universal Protocol. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 18. Journal of Hospital Medicine. 2011; 6 (suppl 2). Accessed April 1, 2020.

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