FAQs released on NPSG.01.01.01, Universal Protocol

Patient Safety Monitor Insider

November 12, 2008

The Joint Commission has released a series of FAQs on Universal Protocol.

The NPSG.01.01.01 FAQ specifically looks at sleeping patients and the nurse’s role in identifying non-communicative or confused patients when another healthcare worker uses two patient identifiers. The Joint Commission states that the purpose behind this is to increase patient safety through such things as medication, diagnostic, and treatment errors. The organization must decide how to assess sleeping/non-communicative/confused patients. The organization must also determine when active involvement is necessary on the part of the responsible nurse or other caregiver. These decisions must be communicated to the staff and be brought about specifically for reasons of patient safety.

The remaining sections of the Universal Protocol FAQs address a number of areas of confusion, including pre-procedure verification, site marking, and time outs.

The Universal Protocol FAQs can be found by clicking here.