Wrong-site surgery still happens 40x/week

The news from the Joint Commission Center for Transforming Healthcare is not good: No matter how much healthcare providers and regulatory bodies stress the need to avoid wrong-site surgery, this sentinel event still occurs about 40 times a week.

That figure was disclosed as the center announced the preliminary results of a wrong-site prevention project with eight hospitals and ambulatory surgery centers (ASCs). The facilities identified the most common causes of wrong-site surgery as scheduling and preoperative/holding processes, ineffective communication, and distractions in the operating room.

The timeout procedure, which held so much promise for eliminating wrong-site procedures when it was first introduced, has been found to be imperfect. Even when the timeout is conducted, not all people in the operating room participate, the facilities reported.

Mark R. Chassin, MD, FACP, MPP, MPH, president of The Joint Commission, said during a news conference that the hospitals' reports were useful in identifying the likely causes of wrong-site procedures throughout the health system. "The eight hospitals and ASCs identified where errors can creep into the process and took steps to correct them," Chassin said. "We hope to use their experience as a roadmap to measure risks."

All facilities and physicians who perform invasive procedures are at some degree of risk, he said. In 2010, wrong-site surgery was the third most common sentinel event reported, he noted. "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," Chassin said. "Unless an organization has taken a systematic approach to studying its own processes, it is flying blind."

Because wrong-site surgeries are relatively rare events, they are difficult to study, he noted. Research has shown, however, that there is usually no single root cause of failure. More often, wrong-site surgeries occur as the result of a number of small errors that compound each other and lead to the final mistake, Chassin said.

Marking the incision site should help avoid wrong-site surgery, but the execution varies greatly within facilities, said Mary Reich Cooper, MD, JD, senior vice president and chief quality officer of Lifespan Corp., who also spoke at the press conference. Lifespan has four hospitals in Providence, RI, that participated in the wrong-site project. "In the past, the mark was made in the holding area," Cooper said. "We found discrepancies between what was seen there before the surgeon arrived and what he thought he was doing in the operating room. So now we have surgeons go out to the holding area to make the initial mark. Then in the OR before the procedure starts, we affirm that mark, asking if everyone sees the mark. We shut down our OR for a day and put everyone through training. Every new staffer gets the same training."

The type of pen also makes a big difference, she said. "Sometimes, the mark was washed away during the prep," Cooper said. "So make certain that only approved indelible pens are used. This was a simple but important intervention."

Tom Feldman, chief executive officer at the Center for Health Ambulatory Surgery Center in Peoria, IL, noted that timeouts were handled inconsistently in several participating locations. "Was the timeout occurring before prep and drape, or after? Who leads the time out: the circulating nurse or the attending surgeon?" Feldman said. "We closed some gaps and decreased variation. That helps everyone in awareness."