Joint Commission Center for Transforming Healthcare Aims to Reduce Risk of Wrong-Site Surgery

Taking a time-out. Photo courtesy of the Association of periOpaerative Registered Nurses (AORN).

Healthcare professionals and patients all agree that wrong site surgery is a serious and preventable adverse event that should never happen. Although reporting is not mandatory in most states, some estimates put the national incidence rate, which includes wrong patient, wrong procedure, wrong site, and wrong side surgeries, as high as 40 per week. Recognizing this as a critical patient safety issue, eight U.S. hospitals and ambulatory surgical centers teamed up with the Joint Commission Center for Transforming Healthcare to address the problem. The Center and the participating organizations used methods such as Lean Six Sigma and change management to discover the causes of and put a stop to these preventable breakdowns in patient care.

The participating hospitals and ambulatory surgical centers found that problems with scheduling and pre-op/holding processes, as well as ineffective communication and distractions in the operating room contributed to increasing the risk of wrong-site surgery. In addition, a Time Out without full participation by all key people in the operating room was identified as another contributing factor that increased risk. These contributing factors vary by organization and by event. This underscores the importance of understanding the specific contributing factors that increase risk in each organization so that appropriate solutions can be targeted to reduce the specific risks in that organizations processes.

By reinforcing quality and measurement, emphasizing a culture of safety, strengthening knowledge about wrong site surgery, and improving consistency in surgical processes, the eight participating health care organizations and the Center found that opportunities for errors or defects could be reduced. For example, addressing documentation and verification issues in the pre-op/holding areas decreased defective cases from a baseline of 52 percent to 19 percent. Defects are the causes of and risks for wrong site surgery. In turn, the incidence of cases containing more than one defect decreased 72 percent.

The focus on eliminating defects is important because a single operative case has multiple opportunities for defects. When there are multiple defects in a single case, it can further increase the risk of an error reaching the patient. Additionally, it was found that defective cases occurred more frequently when more than one procedure was performed.

The eight hospitals and ambulatory surgical centers that volunteered to address wrong site surgery as a critical patient safety problem are:

- AnMed Health, Anderson, South Carolina

- Center for Health Ambulatory Surgery Center, Peoria, Illinois

- Holy Spirit Hospital, Camp Hill, Pennsylvania

- La Veta Surgical Center, Orange, California

- Lifespan-Rhode Island Hospital, Providence, Rhode Island

- The Mount Sinai Medical Center, New York, New York

- Seven Hills Surgery Center, Henderson, Nevada

- Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania

"While wrong-site surgery is not an everyday occurrence, all facilities and physicians who perform invasive procedures are at some degree of risk. The magnitude of this risk is often unknown or undefined. Providers who ignore this fact, or rely on the absence of such events in the past as a guarantee of future safety, do so at their peril. Unless an organization has taken a systematic approach to studying its own processes, it is flying blind," says Mark R. Chassin, MD, FACP, MPP, MPH, president of the Joint Commission. "These eight organizations are leading the way in finding specific solutions to the complex problem of wrong-site surgery."

This project addresses the problem of wrong-site surgery using Robust Process Improvement (RPI) methods. RPI is a fact-based, systematic, and data-driven problem-solving methodology. It incorporates tools, concepts and methods from Lean Six Sigma and change management methodologies. Using RPI, the project teams measure the magnitude of the problem (or, in the case of wrong site surgery, specific problems that increase the risk of this event), pinpoint the contributing causes, develop specific solutions that are targeted to each cause, and thoroughly test the solutions. Although invasive surgical procedures occur in many settings, the scope of this project included all procedures performed in the operating room and regional blocks performed by anesthesia either in the preoperative area or the operating room. Within the project scope, the timeframe begins at the time a procedure is scheduled for surgery and ends with incision.

Wrong-site surgery includes invasive procedures on the wrong patient as well as wrong procedure, wrong site, and wrong side surgeries. The Joint Commission has been at the forefront of the wrong site surgery issue for many years, issuing Sentinel Event Alert newsletters in 1998 and 2001 on wrong-site surgery. The Joint Commission later convened a Wrong-Site Surgery Summit that led to the development of the Universal Protocol, a standardized approach to eliminating wrong site surgery. Use of the Universal Protocol, which includes a pre-procedure verification, site marking and a Time Out, is an accreditation requirement for Joint Commission-accredited hospitals, ambulatory care and office-based surgery facilities.

In addition to wrong site surgery, the Center is working to reduce surgical site infections following colorectal surgery through a project launched in August 2010 in collaboration with the American College of Surgeons. The solutions for this project are expected to be published in late 2011 or early 2012. A new project, Preventing Avoidable Heart Failure Hospitalizations, launched in March 2011.

All Joint Commission-accredited healthcare organizations have access to the solutions through the Targeted Solutions Tool (TST), which provides a step-by-step process to measure performance, identify barriers to excellent performance, and implement the Centers proven solutions that are customized to address an organizations specific barriers. The first set of targeted solutions, created by eight of the countrys leading hospitals and health care systems working in collaboration with the Center, focuses on improving hand hygiene. Accredited organizations can access the TST and hand hygiene solutions on their secure Joint Commission Connect extranet. Targeted solutions for wrong site surgery are expected to be added to the TST in the fall of 2011. Solutions for hand-off communications, another Center project, are expected to be added in late 2011. Future projects are expected to focus on medication errors, and other aspects of infection control.