Pathologist performed fine needle aspirations & implementation of JCAHO Universal Protocol and "Time out"

The adherence to the principles of the Universal Protocol for preventing wrong site, wrong procedure and wrong person surgical or invasive procedures is a requirement for all Joint Commission accredited organizations. Fine needle aspirations are considered invasive procedures, and cytopathologists performing this procedure need to be cognizant and compliant with the requirements of this Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Protocol. This article gives background perspective on the development of the Universal Protocol. It also elaborates the JCAHO National Patients Safety Goals regarding the performance of fine needle aspirations. The compliance with the Universal Protocol for performance of fine needle aspirations is now mandated for all cytopathologists who perform fine needle aspirations and this present paper provides a guideline for fulfilling the requirements of the Universal Protocol for practicing cytopathologists.