Wrong-site surgeries risk reduced during pilot project

The Joint Commission in June cited early progress on a pilot project designed to identify and prevent the problems that can lead to wrong-site and wrong-patient surgeries.

The organizations participating in the project, including La Veta Surgical Center in Orange, Calif., and Thomas Jefferson University Hospitals in Philadelphia, were able to reduce the proportion of surgical cases in which there was a process-related defect that could result in a wrong procedure. That proportion was reduced from a baseline of 52% to 19%.

Because wrong procedures are so rare, the pilot project is using these intermediate process metrics to gauge how well hospitals and surgical centers are doing at preventing surgery mix-ups. That means that the organizations taking part in the project reduced their risk of having a wrong-site and wrong-patient surgery.

In 2004, the Joint Commission mandated a three-step "universal protocol" requiring physicians and other health professionals to perform a pre-surgery verification process, mark the correct site for the procedure and conduct a "timeout" discussion as a final check before the procedure begins. "It turns out that this is a much more complicated problem than it might seem to be at first," said Mark R. Chassin, MD, president of the Joint Commission. "There isn't a simple way to prevent wrong-site surgery. It takes a comprehensive approach."

The commission's universal protocol is correct in principle, but the challenge is for hospitals, ambulatory surgery centers and physician offices that do procedures to figure out how to apply those principles in practice, Dr. Chassin said.

For example, verifying the patient's identity and the procedure to be performed is seemingly straightforward. But the eight health care organizations taking part in the commission's Center for Transforming Healthcare project on wrong-site surgery found that the procedure-scheduling process introduced errors nearly 40% of the time. These mistakes may not have resulted in a wrong procedure, but these process defects raise the risk of wrong-site surgery, Dr. Chassin said.

"There are risks at all phases of the process. These include missing documents during the preoperative preparation, ineffective or incomplete procedures when marking the site, to key omissions during the timeout process before the procedure, which is the last chance to correctly identify the patient and the procedure," he said.

One of the project's participants is Lifespan Corp., a four-hospital health system based in Providence, R.I., that includes Rhode Island Hospital, which experienced five wrong-site surgeries between January 2007 and October 2009. The state's health department fined the hospital $150,000 and ordered the hospital to video-record procedures. Since then, Rhode Island Hospital has changed how charts are delivered to prevent incorrectly identified patients from getting into the operating room.

The timeout process also has been changed, said Mary Reich Cooper, MD, Lifespan's senior vice president and chief quality officer. "We stopped all other activities so that everyone could focus on that last opportunity to correct mistakes to make sure we didn't make the incision in the wrong place," Dr. Cooper said. "Every single person in the operating room needs to stop what they're doing. We script the staff at that point, asking, 'Can everyone see the mark?' and everyone has to respond."

Wrong surgeries are estimated to occur as often as 40 times a week in the U.S., the commission said. The number of wrong procedures reported to a Colorado medical liability insurer actually rose between 2002 and 2008, according to an October 2010 Archives of Surgery study.

When it comes to procedures designed to prevent errors that everyone agrees never should occur, officials said consistency is the goal. At the six-operating room Center for Health Ambulatory Surgery Center in Peoria, Ill., the procedures for marking sites -- the surgeon's initials, "yes" and "OK" were all used -- and when exactly the timeout took place were all over the map.

In some cases, participating in the project helped organizations uncover simple mistakes that could result in tragedy. For example, indelible ink was not always used to mark the surgical site. Or the mark was too far from the surgical site and was not visible when the body was draped.