ACEP endorses rules for avoiding wrong sites

The American College of Emergency Physicians (ACEP) in Irving, TX, has joined more than 40 organizations endorsing a new universal protocol to standardize pre-surgery procedures for verifying the correct patient, the correct procedure, and the correct surgical site. The protocol focuses attention on marking the surgical site, involving the patient in the marking process, and at least in the operating room, taking a final time-out to double-check information among all members of the surgical team.

The protocol was developed by the Joint Commission on Accreditation of Healthcare Organizations with several organizations that also have been addressing the problem in recent years. Joint Commission president Dennis S. O’Leary, MD, reports that despite years of intense focus on the problem of wrong-site surgery, the organization continues to receive five to eight new reports of wrong-site surgery every month.

The Joint Commission’s new national patient safety goals, which became effective Jan. 1, 2003, include a goal to eliminate wrong-site surgery.

The universal protocol officially will become effective on July 1, 2004, for all Joint Commission-accredited hospitals, ambulatory care surgery centers, and office-based surgery sites. Compliance may require substantial changes in policy and procedure at some hospitals, says O’Leary. Though much of the protocol already has been in place as part of the patient safety goals, he explains.that recent unannounced Joint Commission site visits revealed 36% of accredited organizations are not marking the operative site.

How much the universal protocol applies to ED procedures may require some judgment, but O’Leary points out it is not exclusively for use in the surgery department. Procedures can be performed on the wrong person or wrong site in the ED, he says, and the right procedure can be performed on the wrong person.

While the Joint Commission’s protocol leaves room for deciding how many of the steps apply to specific procedures in the ED, O’Leary adds the Joint Commission expects all health care providers to adhere to the spirit of the protocol: Whenever possible, take time to pause and confirm with others and through documentation that you are about to perform the correct procedure. And when possible, mark the operative site ahead of time.

Kaiser Foundation Hospital in San Francisco has adopted the universal protocol with enthusiasm, and that adoption includes the ED, says Linda Groah, RN, chief nurse executive and director of hospital operations.

"I know of a case where a chest tube was put into the wrong side of a patient’s chest in the ED," she says. "This is an example of how there are opportunities to implement this universal protocol in the emergency room. There is great value in pausing to confirm that you’re doing the right thing on the right patient."


For more information on wrong-site surgery, contact:

  • Linda Groah, RN, Chief Nurse Executive and Director of Hospital Operations, Kaiser Foundation Hospital, 2425 Geary Blvd., San Francisco, CA 94115. Phone: (415) 929-4000.