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Since mid-2004, The Joint Commission (TJC) has held all accredited hospitals to task for enforcing use of the Universal Protocol (UP), a practice designed to improve procedural safety by having clinicians go through a three-step process to insure that when they perform a procedure, they are performing the right procedure, on the right patient, in the right place.

ED Accreditation Update: Use of the Universal Protocol in the ED: Clarifications and recommendations for enhanced procedural safety