Joint Commission, providers address wrong-site surgeries

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Eight hospitals and ambulatory surgical centers collaborated with the Joint Commission Center for Transforming Healthcare to eliminate wrong-patient, wrong-procedure and wrong-site surgeries—which some estimates put as high as 40 incidents per week in the U.S.

Hospitals and ambulatory surgical centers found that problems with scheduling, pre-operation holding processes, ineffective communication and distractions in the operating room were causes of some of the incidents, according to the Joint Commission. Addressing those problems reduced the number.

“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,” the Joint Commission noted. “In turn, the incidence of cases containing more than one defect decreased 72 percent.”

The eight participating hospitals were: AnMed Health in Anderson, S.C.; Center for Health Ambulatory Surgery Center in Peoria, Ill.; Holy Spirit Hospital in Camp Hill, Pa.; La Veta Surgical Center in Orange, Calif.; Rhode Island Hospital, Providence in R.I.; Mount Sinai Medical Center in New York City; Seven Hills Surgery Center in Henderson, Nev.; and Thomas Jefferson University Hospitals in Philadelphia.

Those hospitals found that they could reduce the number of incidents “by reinforcing quality and measurement, emphasizing a culture of safety, strengthening knowledge about wrong-site surgery, and improving consistency in surgical practices.”

“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,” said Mark R. Chassin, MD, MPH, president of the Joint Commission.