All the hospitals and outpatient surgical centers in Rhode Island have agreed to follow the same process to prevent errors in surgery.

The protocol establishes detailed new rules intended to prevent the wrong-site surgeries that have embarrassed local hospitals in recent years. It also lowers the risk of confusion for the many doctors and nurses who work at more than one place, and who will now all follow the same routine.

In announcing the new rules Tuesday, the Hospital Association of Rhode Island said Rhode Island is the first state in which a uniform protocol has been voluntarily adopted by all surgical providers. The protocol was developed over 18 months of consultation with hospital and health-care leaders and the Joint Commission, the agency that accredits hospitals.

All the providers — 12 hospitals and 21 surgical centers –– agreed to start rolling out the protocol on Wednesday, but it is expected to take a year before every organization has trained staff and fully implemented the new rules.

The protocol has several features that will require the state’s roughly 300 surgeons and thousands of operating-room nurses to change the way they work:

1. The surgical site is marked after a three-way consultation with the surgeon, one other licensed practitioner (such as a nurse) and the patient or patient’s guardian. Once all three agree on the site, it is marked with the surgeon’s initials.

2. The operating room team follows a briefing process. All team members introduce themselves and state their roles. The surgeon identifies the patient, the procedure and the site, and discusses the plan for the surgery, including the patient’s medications, lab or imaging documentation and necessary equipment.

3. The surgeon initiates a time-out before the operation, in which everyone agrees on the patient, procedure and site, and verifies that the surgeon’s initials are visible after prepping and draping.

4. Before leaving the operating room, the surgeon leads a debriefing process that includes reviewing the postoperative plan of care and discussing what worked well and what could have been done differently.

Dr. William Cioffi, surgeon-in-chief at Rhode Island Hospital, said that safety efforts must walk a fine line, requiring accountability without overemphasizing blame; each member of the surgical team has responsibilities to meet but also must feel free to acknowledge and report errors.

The new rules clearly put the surgeon in the driver’s seat –– but also mandate that every member of the surgical team speak up if something seems amiss, he said. “We have to have a culture where people can say ‘stop,’ ” he said.

“The policies themselves are not going to fix this,” Cioffi said. Instead, hospitals need to improve communication and develop a “culture of safety.”

Cioffi said the hospitals will train staff through lectures and a video, and will also devise ways to make sure the protocol is properly and uniformly adopted around the state. “This is a great first step. It’s not the end of the process,” he said.

Dr. Kathleen C. Hittner, chairwoman of the hospital association’s board of trustees and president of Miriam Hospital, said that safety-improvement efforts will continue. “This is not the end of our journey,” she said at a news conference at Miriam. “We will definitely have more to tell you over the coming years.”

“It’s very reassuring as a professional and consumer to see we’ve come this far,” said Donna Policastro, executive director of the Rhode Island State Nurses Association, which endorsed the effort along with the Rhode Island Medical Society and the Rhode Island chapter of the American College of Surgeons.

Mark Crafton, the Joint Commission’s executive director for state and external relations, worked with the hospital association to develop the new protocol. He praised the rules themselves –– and the fact that they had been developed. “The attention that they’re bringing to this issue, I think, can only help prevent these wrong-site surgeries,” he said.

“They have steps built into their protocol that allow all team members to be accountable and responsible for speaking up if they believe that something doesn’t look right,” Crafton said.

Five wrong-site surgeries have been reported in Rhode Island since 2007, all at either Rhode Island Hospital or Miriam Hospital, which are part of the Lifespan group. Additionally, in June, a surgeon at Miriam anesthetized the wrong eye of an eye-surgery patient, but the error was noticed before the patient entered the operating room.

Despite all the attention these incidents have attracted, Crafton said, “We don’t have any data that would show that the rate of wrong-site surgeries is more frequent in Rhode Island versus other states. I think it’s clear from the data we do collect on a voluntary basis and media reports that wrong-site surgery is an issue around the country.”

Some of the recent errors in Rhode Island did not result from inadequate procedures –– but from failure to follow them. “That’s another challenge that the hospitals in Rhode Island will have to work on,” Crafton said. “How do you take a good checklist and make sure that it’s actually embedded in the operating procedures?”

The Joint Commission plans to work with hospitals to find ways to “weave” checklists and protocols into normal operating room activities, he said.

ffreyer@projo.com