Although many surgical safety experts refer to wrong-site surgeries as "never events" because they should never happen, wrong-site surgeries continue to injure patients all too often.
A recent project that teamed the Joint Commission Center for Transforming Healthcare with eight hospitals and ambulatory surgical centers yielded 29 causes of, and possible solutions for preventing this form of medical malpractice.
Occurring an estimated 40 times a week, wrong site surgeries happen when a physician operates on the wrong part of the body or on the wrong patient. Studying every stage of surgery, from scheduling to the operating room, the Joint Commission released a list of 29 causes and solutions.
The commission also plans to launch an electronic solutions tool in the fourth quarter of 2011 to aid in the prevention of wrong-site surgery. Currently tested in six ambulatory surgical centers, the tool will eventually be available to organizations accredited by the Joint Commission.
Although there is no singular cause for all wrong-site surgeries, the Joint Commission identified several common causes. The absence of essential documents like a history and physical, consent or surgeon's orders during the scheduling process is one of the causes cited by the Joint Commission. The commission suggested that medical professionals confirm documents that contain critical information to the verification process are present and accurate the day before a surgery.
Inconsistency in surgical site marking by physicians is a problematic practice during pre-op and holding according to the commission, which suggests medical establishments offer ongoing education and just in time coaching to remedy it.
The list made repeated references to the "time out" phase of surgical preparation, when surgeons are supposed to confirm patient information. From distractions and rushing during the time out phase to a lack of full participation, the commission offers several solutions, such as developing a role-based time out process that works for each respective organization.
Causes weren't confined to the surgery process alone. In fact, flaws in organization also popped up on the commission's radar. The Joint Commission listed "inconsistent organizational focus on patient safety" as one of the causes for wrong-site surgery, suggesting that organizations establish a measurement system to identify inconsistencies.
Source: Becker's ASC Review, "Joint Commission Identifies 29 Main Causes of Wrong-Site Surgery, Offers Solutions," Rob Kurtz, 6/30/2011