March 16, 2009 | | Comments 0
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Joint Commission releases more FAQs

The Joint Commission has released another set of FAQs, this time addressing some emergency management, environment of care, and Universal Protocol concerns. Though you can see the full list of FAQs by clicking here, I’m going to highlight the FAQs for the Universal Protocol, as it has been a major trouble spot for hospitals and is a topic we’ve talked about in other AHAP Blog posts.

  • Bilateral procedures: The Joint Commission has addressed the issue of performing site marking for a bilateral procedure by saying it’s not required, but it is recommended. The intent of the Universal Protocol has been to specifically note the correct side of the patient for those surgeries requiring laterality, but this new FAQ was released in acknowledgement that it is possible to perform the wrong bilateral procedure.
  • Documenting the timeout: The Joint Commission has addressed the outcry it received from the field about how onerous a requirement it was to require each element of the timeout be documented individually. This FAQ specifies that it is acceptable to create a check box or brief note that documents that all parts of the timeout were completed. This simple documentation must be in the same part of a patient’s record for each patient, and the components of the full time out have to be listed elsewhere (like in a policy or procedure), but one check box will comply with the Universal Protocol.

Has your facility struggled with the 2009 Universal Protocol? Do these recent FAQs clear up any issues you may have been having with documentation?

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Heather Comak About the Author: Heather Comak is the Assistant Director of the Association for Healthcare Accreditation Professionals and a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety. Contact Heather by e-mailing her at

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