New Tool from the Joint Commission to Improve Surgical Consultations

Retracing a team’s steps helps understand what led to confusion. “In many of these instances, the consent form matched the surgical schedule and the entire team remained convinced they were correct,” Dr. Haeck continued. “What produced this misperception was the dictation at the original examination where the surgeon, busy or distracted, left the consultation room and produced paperwork or a scheduling form with the wrong site included. The no-brainer here is that in each of these instances, no one asked the patient.”

A New Tool

Health care professionals and patients concur that wrong-site surgery should never happen. While most states do not require facilities to report these adverse events, some estimates from the Joint Commission suggest that the national incidence rate of wrong-patient, wrong-procedure, wrong-site and wrong-side surgeries may be as high as 40 per week. Viewing this as a major threat to patient safety, eight U.S. hospitals and ambulatory surgical centers collaborated with the Joint Commission Center for Transforming Healthcare (CTH).

The wrong-site surgery solutions provided by the TST are the culmination of work started in July 2009 by CTH and the Lifespan health system in Rhode Island. Their goal was to improve safeguards designed to prevent wrong-site, wrong-side, wrong-procedure and wrong-patient surgical procedures. In 2010, four additional hospitals and three ambulatory surgical centers joined the project.

Among the problems uncovered was the fact that a time out without complete participation by all key people in the operating room contributed to the risk of wrong-site surgery. Issues with scheduling and pre-op/holding processes, as well as ineffective communication and distractions in the operating room, also heightened the risk. Addressing problems with documentation and verification in the pre-op/holding areas reduced defective cases from a baseline of 52 percent to 19 percent. Defects are the causes of and risks for wrong-site surgery. As a result, the incidence of cases with more than one defect dropped 72 percent.

The original participating organizations used Robust Process Improvement (RPI) to identify targeted solutions. RPI is a fact-based, systematic and data-driven problem-solving methodology that incorporates tools and concepts from Lean Six Sigma and change management methodologies. Project teams measure the magnitude of the problem (in the case of wrong-site surgery, specific issues that increase the risk of this event) and pinpoint the contributing causes, developing particular solutions targeted to each cause and thoroughly testing them in real-life situations.

Those participating in CTH’s project identified 29 main causes of wrong-site surgeries that stemmed from the organizational culture or that occurred during scheduling, in pre-op/holding or in the operating room. During the project, the original eight project organizations decreased the number of surgical cases with risks by 46 percent in the scheduling area, 63 percent in pre-op and 51 percent in the operating room. Hospitals and ambulatory surgical centers pilot-testing the TST experienced the same gains as the original participants.