Wrong-Site Surgery Occurs 40 Times a Week

Preliminary results of a new study show that there is usually no single root cause for wrong-site surgery, and that these events are frequently the result of a cascade of small errors.

Researchers participating in the US Joint Commission Center for Transforming Healthcare (Oakbrook Terrace, IL, USA) announced the preliminary results of a project involving eight hospitals and ambulatory surgery centers. The facilities found that problems with scheduling and preoperative/holding processes, as well as ineffective communication and distractions in the operating room, contributed to increasing the risk for wrong-site surgery. A "time out" without full participation by all key people in the operating room was identified as another contributing factor that increased risk.

Unapproved pens used to mark the surgery site were also a part of the problem; sometimes the mark was washed away during the patient preparation. Making certain that only approved indelible pens are used was therefore a simple but important intervention. The facilities also found that addressing documentation and verification issues in the preoperative and holding areas decreased defective cases that increase the risk for wrong-site surgery from a baseline of 52% to 19%. In turn, the incidence of cases containing more than one defect decreased by 72%.

“We found that in 39% of cases, errors were introduced that increased risk,” said president of the joint commission Mark Chassin, MD, MPP, MPH. “The biggest was inadequate information about the patient. Often, the information is taken by a staffer in the surgeon's office, who may have to deal with several hospitals and different protocols. Confusion can result. The solution is a carefully standardized way of collecting information.”

“The 8 hospitals identified where errors can creep into the process and took steps to correct them. All facilities and physicians who perform invasive procedures are at some degree of risk; the magnitude of this risk is often unknown or undefined,” added Dr. Chassin. “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.”

Related Links:
Joint Commission Center for Transforming Healthcare