Hospital already was trying to prevent errors

Ironically, the fifth wrong-site surgery occurred at Rhode Island Hospital as it continues working with The Joint Commission's Center for Transforming Healthcare on improving surgical protocols. The hospital volunteered for the project to improve the safeguards to prevent patients from undergoing wrong-site, wrong-side, and wrong-patient surgical procedures.

Rhode Island Hospital CEO Timothy Babineau said the hospital has put "a tremendous amount of work" into error prevention after the string of embarrassing wrong-site surgeries, which included participating in the national pilot program to prevent surgical errors. In June 2009, the Hospital Association of Rhode Island announced that all hospitals and surgical centers in the state had agreed to follow the same process to prevent surgical errors, making Rhode Island the first state in which a uniform protocol was voluntarily adopted by all surgical providers.

"This error reminds us of the extraordinary complexity and difficulties in preventing medical errors — particularly wrong-site surgery," Babineau said.

The Joint Commission project is addressing the problem of wrong-site surgery using Robust Process Improvement (RPI), a systematic and data-driven, problem-solving methodology. RPI incorporates specific tools and methods from Lean Six Sigma and change management methodologies. The project team includes hospital leadership, surgeons, operating room staff, and physicians from Rhode Island Hospital and a team from the center that is expert in RPI.

The Joint Commission Center for Transforming Healthcare recently developed and recommended solutions that are designed to reduce the risk of wrong-site surgery at Rhode Island Hospital. The solutions include:

• Check and verify documents at the time of scheduling a procedure.

• Surgeon to mark the correct surgical site in the preoperative area.

• Point to the surgical site during the timeout.

• Streamline paperwork to further decrease distractions.

• Define the roles and responsibilities of team members for conducting preoperative marking, identification, and timeout.

• Empower everyone on the team to stop the process if there are any concerns.

These solutions are focused on caregivers being in the right roles and performing the right tasks. The solutions also build on The Joint Commission's Universal Protocol. Rhode Island Hospital will be testing these solutions over the next few months, according to The Joint Commission.

Patient safety experts also urge hospitals to involve the patient and family members in efforts to avoid wrong-site surgery. Martine Ehrenclou, author of Critical Conditions ... The Essential Hospital Guide to Get Your Loved One Out Alive, notes that there is a growing trend for health providers to actively encourage family members to act as an advocate for the patient who is going to have surgery.

"The family member can ask the surgeon, anesthesiologist, or nurse to verbally repeat exactly which site is to be operated on and request that it be marked there and then," she says. "If no family member is available, the patient can also mark the surgery site on his or her body before entering the operating room. Hospitalized patients need watchdogs. What better watchdog than a family member who has a personal vested interest in the safety of the patient?"


For more information on patient advocacy, contact:

• Martine Ehrenclou, author of Critical Conditions ... The Essential Hospital Guide to Get Your Loved One Out Alive, Los Angeles. Telephone: (310) 458-6047. E-mail: