JCAHO outlines causes of most wrong-site surgery

Operating on the wrong part of a patient’s body is an obvious sign that there’s a fault in your operating room (OR) system. New advice from the Joint Commission on the Accreditation of Health care Organizations (JCAHO) in Oakbrook Terrace, IL, can help you pinpoint the problem.

The mistake usually can be traced to multiple surgeons, multiple procedures, pressure to operate quickly, and unusual body characteristics, according to a recent JCAHO report. Its accreditation committee has reviewed 15 cases of wrong-site surgery in the two years since the sentinel event policy has been in place. A root cause analysis was conducted after each incident, and JCAHO used that information to determine the common characteristics of the incidents.

Wrong-site surgery occurred most commonly in orthopedic procedures, accounting for 10 of the incidents; there also were three urologic and two neurologic procedures. JCAHO reports that these factors apparently contributed to the wrong-site surgeries:

o More than one surgeon was involved. This could be because multiple surgeries were anticipated, or the patient’s case was transferred from one surgeon to another.

o There were multiple surgeries on one visit to the OR. The risk is greater if multiple surgeries are on both sides of the patient.

o The surgical team was pressed for time. The pressure to move quickly could be related to an unusual starting time or pressure to hurry through pre-op procedures so the surgeon can start working.

o The patient had unusual characteristics. Any physical deformity could complicate the preoperative process and the procedure. Extreme obesity, for instance, can cause the surgical team to alter normal equipment setup and patient positioning.

As might be expected, poor communication is usually behind the wrong-site surgery incidents. The 15 hospitals cited the main causes as miscommunication and faults with pre-op assessment and the procedures used to verify the operative site. The communication problems fell into two broad categories: 1) failure to engage the patient or family in the process of identifying the correct surgical site and 2) incomplete or inaccurate communication among surgical team members. The poor communication among team members often took the form of excluding some members, such as the surgical technicians, from the site verification process. In other cases, the team relied solely on the surgeon to verify the correct operative site.

JCAHO cited these other contributing factors:

• failure to review medical records or imaging studies immediately before operating;

• no formal procedure for verifying correct site;

• no final OR check before starting procedure;

• no oral communication in verification process;

• failure to have all relevant information sources in OR;

• not using a checklist;

• atmosphere in which surgical team members felt they were not permitted to point out errors;

• attitude that surgeons should never be questioned.

With those findings in mind, JCAHO makes the following recommendations for preventing wrong-site surgeries:

• Clearly mark the operative site.

• Involve the patient in marking process to improve its reliability.

• Require each surgical team member to orally verify the correct surgical site.

• Use a checklist that includes any documents mentioning the correct site — including the medical record, X-rays, other imaging studies, informed consent documents, the OR record, and the anesthesia record — and direct observation of the marked operative site on the patient;

• ensure the surgeon personally takes part in obtaining informed consent;

• monitor OR procedures to ensure verification procedures are followed, especially for high-risk ones.