Errors: What we have is a failure to communicate

An analysis of the wrong-site surgery incidents reported to the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations indicates that shoddy communication is the main cause of most wrong-site surgery.

Wrong-site surgery is reported to the Joint Commission as a sentinel event. Of the 150 reports, 126 have root-cause analysis information. Forty-one percent were in orthopedic/podiatric surgery; 20% were in general surgery; 14% neurosurgery; 11% urologic surgery; and the remaining procedures were in dental/oral maxillofacial, cardiovascular-thoracic, ear-nose-throat, and ophthalmologic surgery.

Predictably, 67% involved surgery on the wrong body part or site. Thirteen percent involved surgery on the wrong patient, and 11% involved the wrong surgical procedure.

When the Joint Commission analyzed the factors contributing to the accidents, patterns emerged. Emergency cases accounted for 19%; and unusual physical characteristics, including morbid obesity or physical deformity, occurred in 16%. The operative teams faced unusual time pressures to start or complete the procedure in 13%, and unusual equipment or setup in the operating room in another 13%. The Joint Commission also reports the involvement of multiple surgeons can be factor, with 13% of the cases involving more than one surgeon. Multiple procedures being performed during a single surgical visit also were a risk, found in 10% of the cases.

The hospitals identified root causes as part of their analyses, with most reporting that the root cause was a breakdown in communication between surgical team members and the patient and family. Some also reported that marking of the surgical site was not required but would have helped. Other root causes were a lack of verification in the operating room, incomplete patient assessment, staffing issues, distraction, and availability of pertinent information in the operating room.