OAKBROOK TERRACE, IL— 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 organization’s 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:
“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, M.D., FACP, M.P.P., M.P.H., president, 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 health care 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 Center’s proven solutions that are customized to address an organization’s specific barriers. The first set of targeted solutions, created by eight of the country’s 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.
Statements from the Center’s participating organizations
“Being cared for in a safe environment is something all patients, no matter how routine the procedure, should expect and experience in the hospital. At Rhode Island Hospital, as well as at all the hospitals in the Lifespan system, we take patient safety seriously and have made it a top priority for everyone in our organization. This is why we are participating with The Joint Commission in the Center for Transforming Healthcare to look for ways and share best practices about ways to prevent wrong side surgeries. At Lifespan, we have put aggressive systems in place that help to further protect patients from medical errors, but we also know that staying ahead of these sorts of errors involves a continued commitment to learn more and share our experiences."
Mary Reich Cooper, M.D., J.D., senior vice president and chief quality officer, Lifespan Corporation, Providence, Rhode Island
“We were honored to be asked by The Joint Commission and Ambulatory Surgery Center Association to participate in their Wrong Site Surgery Pilot Project. As we continue to work towards being more efficient and providing the most cost effective, yet state of the art outpatient surgical services, our patient’s safety is our number one priority. Working with the Center for Transforming Healthcare gave us the opportunity to review our own approach and gain insight from other facilities around the country. We were proud to share some of our practices in a similar fashion with them. Our recent accreditation survey, continued high patient satisfaction scores, attractive facility and location, and participation in many insurance plans, make us a destination spot for outpatient surgery in the area."
Thomas Feldman, CEO, Center for Health, ASC, LLC, Peoria, Illinois
“It has been a privilege to participate in the Joint Commission Center for Transforming Healthcare Wrong Site Surgery pilot. Our La Veta Surgical Center is honored to represent Surgical Care Affiliates and all ambulatory surgery centers that collectively performed over 22 million surgeries nationally in 2010. As a participant in the project, we were able to participate in the development of tools and processes that will be shared with countless surgical providers across the country through the Joint Commission Center for Transforming Healthcare’s website. We take great pride in knowing that not only were we able to refine our internal processes for preventing wrong site surgeries, but that we assisted in helping other organizations to do the same."
Andrew Hayek, president and CEO, Surgical Care Affiliates, Chicago, Illinois
“AnMed Health physicians perform nearly 10,000 surgeries each year, and we’re committed to ensuring every patient receives excellent care. Participating in the Wrong Site Surgery project gave AnMed Health a unique opportunity to help develop tools that will improve the quality of care at hospitals and health systems across the country. The project aligned perfectly with our vision to be recognized and celebrated as the gold standard for health care quality and community health improvement. We look forward to seeing how the solutions identified in this process make a difference in our patients’ lives for years to come."
Tina Jury, vice president for patient care services and chief nursing officer, AnMed Health, Anderson, South Carolina
“Patients in the United States undergo millions of surgical procedures each year. A wrong site surgery event should never occur. As providers, we must be aware of the risks of such events and be proactive in the development of successful tools that can be utilized in an effort to prevent these types of events from occurring. As we look forward to the future of health care for Americans, the delivery of high quality, efficient care combined with excellent outcomes should be the goal of all health care providers. One of the crucial elements of creating this success is to develop systems that help build trust between patients and their providers. The prevention of wrong site surgery events is one of the keys to this process."
Rudy R. Manthei, D.O., FOCOO, CEO, Seven Hills Surgery Center, Henderson, Nevada
“Quality care will always be the heart and soul of our mission at Holy Spirit Hospital. The patients who trust us with their very lives deserve nothing less. We are proud of how we handle patient safety, but we wanted to be proactive and develop protocols so we never have a wrong site surgery. We joined the Center for Transforming Healthcare project because we wanted to put into place an evidence-based best practice that eliminates the possibility of having a wrong site surgery. We will continue to focus on proven ways of improving the quality of clinical care."
Joseph Torchia, M.D., chief medical officer, Holy Spirit Hospital, Camp Hill, Pennsylvania
“As an academic medical center that performs over 38,000 surgical procedures a year,
Thomas Jefferson University Hospitals’ participation in the Wrong Site Surgery project was a wonderful opportunity to further demonstrate our commitment to the National Patient Safety Goals. The partnership between our physicians, nurses, anesthesiologists and The Joint Commission was a great way to keep front and center our dedication to patient safety and excellence that has been part of our institution for nearly 200 years."
Richard Webster, R.N., vice president for Perioperative Services, Thomas Jefferson University Hospital
"Because ambulatory surgery centers (ASC) represent a unique outpatient care provider model, we are pleased that ASCs were able to participate in this project. Although ASCs already report very low incidences of wrong site, side, patient, procedure and implant surgeries, we look forward to learning more about the ways the results of this project can help improve the high quality of care ASCs already provide."
William Prentice, executive director, Ambulatory Surgery Center Association, Alexandria, Virginia
The Center is grateful for the generous leadership and support of the American Hospital Association, Blue Cross and Blue Shield Association, BD, Ecolab, Cardinal Health, GE Healthcare, GlaxoSmithKline (GSK), Johnson & Johnson and Medline Industries, as well as the support of GOJO Industries, Inc. and Federation of American Hospitals.
For more information about the Joint Commission Center for Transforming Healthcare, visit www.centerfortransforminghealthcare.org.