Want zero surgeries on the wrong site?

Follow solutions from pioneers

Despite Sentinel Event Alerts and partnerships between The Joint Commission and professional organizations, wrong-site surgeries continue at a national rate as high as 40 times per week, according to Mark Chassin, MD, MPP, MPH, president of The Joint Commission and the Center for Transforming Healthcare.

"Awareness about the problem has increased, but we clearly have to do more to get a lot closer to zero," Chassin said.

All surgical providers are at risk, he said. "Unless an organization has taken a systematic approach to studying its own processes and determining its risk of wrong site surgery, it is literally flying blind," Chassin said. (See procedures at highest risk for wrong-site surgery, below.)

Procedures at Risk for Wrong-Site Surgery

  • Orthopedic procedures, which almost always have a laterality to choose from.
  • Spinal surgery, which requires designating the level in the spine that the operation will occur.
  • Ophthalmological surgeries, in which there is a laterality issue in the anesthesia and the operation.
  • More than one surgical procedure scheduled at the same time.

Source: Mark Chassin, MD, MPP, MPH, Joint Commission Center for Transforming Healthcare's Wrong Site Surgery Project News Conference. June 29, 2011.

The Joint Commission worked with five hospitals and three ambulatory surgery centers to focus on solutions. The project found that addressing documentation and verification in the preop holding areas decreased the percentage of risks from a baseline of 52% to 19%. The incidence of cases containing more than one risk decreased by 72%. The Joint Commission Center for Transforming Healthcare held a conference June 29 to share some solutions from the project:

• In scheduling, address lack of standardization for identifying the patient and procedure.

Office schedulers often work with multiple facilities that might have various ways of collecting information, Chassin points out. The solution "is a carefully standardized way of collecting information that has several ways to identify the patient, not just by name, with spelling errors and little typos that can be a problem, and a way to specify exactly what the procedure is, what side of the body it will be performed on, exactly how it will be, so that the information can be conveyed down the line," Chassin said.

• Audit yourself.

Lifespan Corp., a four-hospital system based in Providence, RI, had several public wrong-site surgeries about three years ago. The hospitals now audit themselves every day for every procedure. The leaders determine whether there is a deviation from the script or from the marking, said Mary Cooper, MD, JD, senior vice president and chief quality officer. They have achieved zero deviations from the script and the marking policy, and the facility has not experienced any wrong-site surgeries since these changes, Cooper said.

• Educate physicians.

Leaders at Seven Hills Surgery Center in Henderson, NV, found that if you educate physicians by explaining the significance of the problem and the impact on patient outcomes, they will embrace changes. The education should be done one-to-one, said Rudy Manthei, CEO of Seven Hills Surgery Center and a practicing ophthalmologist.

If you don't challenge physicians' authority, they respond openly, Manthei said. "Once we find the physician that is buying into the system in the process, because it does tend to slow them down intensively, but it does create the leadership necessary for the staff, because staff wants to do the right thing," he said.

At press time, Chassin said the solutions from the wrong-site surgery project will be added to The Joint Commission's Targeted Solutions Tool (http://www.centerfortransforminghealthcare.org/tst.aspx) later this summer. They will be pilot tested later this year, he said.

However, Chassin emphasized, "I don't think anybody needs to wait." If you don't know your risks and haven't measure them, start there, he advised. Standardize the way you collect information, Chassin emphasized. Look at the specific problems on the center's web site and identify the specific kinds of risks, including those that are introduced in scheduling and the risks that are introduced by the failure to have the surgeon mark the site. Also, pay attention to the critical details of how the mark is done, what kind of pen is used, and how close it is to the incision, he says. Look at the time out to determine if it's being done "without full participation, without full attention and without all of the documentation that's necessary to verify the patient's identity, etc.," Chassin said. (See details of these and other solutions, below.)

When the Targeted Solutions Tool is available, there will be specific instructions for organizations to use to measure their risks and identify where they are, he says. "And that's what we certainly would encourage every hospital, surgery center and office that does surgical procedures to do in order to measure its risk and find out where it is so that they can get rid of it," he said.

Surgical site marks need monitoring

In The Joint Commission's recent project focusing on wrong site surgery, the percentage of cases that had risks introduced in the OR from all of issues around time out and marking were at 59% before the interventions and 29% after.

"So, that was a drastic reduction in the risks, and we expect that that will get even better as interventions mature over time," said Mark Chassin, MD, MPP, MPH, president of The Joint Commission (TJC) and the Center for Transforming Healthcare.

At Lifespan Corp.'s four-hospital system based in Providence, RI, the Center for Transforming Healthcare introduced "robust process improvement" to the OR staff over 18 months after a strong of write-site surgeries. The state health department fined the hospital $150,000 and ordered it to hire a consultant to observe surgery for three years, shut down surgery for one day, conduct mandatory training on surgical procedures, and install audio- and video-monitoring equipment in the operating rooms for periodic observation. "At the end of that 18 months, we shut down our operating rooms for a day in order to teach everyone our new protocol for arriving at safe surgery, and I'm pleased to say that it has been approximately 20 months since that occurred without — and I knock on wood every day — any wrong site surgeries in our ORs, says Mary Cooper, MD, JD, senior vice president and chief quality officer for Lifespan Corp., which participated in the TJC project.

At Lifespan, sometimes there were discrepancies between what was seen in the holding area, where the surgeon was not participating, and what the surgeon thought was being done in the OR. "So, we transformed our process with the help of the Center for Transforming Healthcare, by having the surgeons all go out to the holding area to make the initial mark with the patient and the staff in the holding area, and then subsequently affirm that mark by placing their finger on the mark that they had made out in the holding area and asking if everyone could see the mark," Cooper said.

Lifespan shut down the ORs for one day to communicate this system to surgeons, nurses, techs, anesthesiologists, and other staff. The managers took them through didactic and experiential training, and all new staff are required to go through the same training, Cooper said.

Site marking outside the OR

Seven Hills Surgery Center in Henderson, NV, which also participated in TJC Project, identified a most common defect was the site was not marked properly or consistently. The leaders identified that 88% of the site-marking defects were in the pain management room. The leaders changed the policy so that the site marking requirement for pain management was moved to a holding area, which essentially eliminated that problem, Manthei said.

"So, we were able to identify a significant risk factor and created a solution for that," he says.

Mark the surgical site close to where incision will be made, or the mark might be covered by drapes, Chassin said. "So, the specific procedure for how the surgical site is marked, to make sure that it's close enough where the incision will actually be made so that it's visible at the time of the last time out, is a critical intervention," he said.

The Center for Health Ambulatory Surgery Center in Peoria, IL, which participated in TJC project, found variation in the marks, said Tom Feldman, CEO for the center, which participated in TJC project. For example, some physicians would use a dot, while others would write "OK," use their initials, or write the word "yes." "So, there seemed to be some variation there," Feldman said.

Some facilities have found that unapproved pens were used to mark the surgical site, and the mark was washed away during the surgical site prep, Chassin said. Ensuring that approved indelible pens were used was "a simple, but nevertheless, important intervention, to get rid of that part of the problem," he said.

The time out: How to do it right

At the four hospitals that are part of Providence, RI-based Lifespan Corp., every person in the OR stops what they're doing for the time out, according to Mary Cooper, MD, JD, senior vice president and chief quality officer for Lifespan, which participated in a recent project by The Joint Commission focusing on wrong-site surgery.

"We stopped all other activities so that everyone could focus on that last opportunity to correct a mistake, to make sure that we didn't end up making an incision in the wrong place," Cooper said.

The staff point and ask, "Can everyone see the mark?" Everyone has to respond, Cooper said. This step "helped us tremendously," she said.

Turn off the music during the time out, said Mark Chassin, MD, MPP, MPH, president of The Joint Commission and the Center for Transforming Healthcare. Every staff person has a role, and those roles should be specified, Chassin said.

There might be variation in the timing and the initiation of the time out, Chassin said. For example, does the time out occur before the prep and drape, or after? Another area of variation is the initiation and leading of the time out. Did the circulating nurse call for it, or the attending surgeon?

Tom Feldman, CEO for The Center for Health Ambulatory Surgery Center in Peoria, IL, which participated in TJC project, said, that "trying to close some of those gaps and decrease the type of variation, I think, helped everyone in terms of awareness in the OR room."