ENTtoday
  • Home
  • COVID-19
  • Practice Focus
    • Allergy
    • Facial Plastic/Reconstructive
    • Head and Neck
    • Laryngology
    • Otology/Neurotology
    • Pediatric
    • Rhinology
    • Sleep Medicine
  • Departments
    • Issue Archive
    • TRIO Best Practices
      • Allergy
      • Facial Plastic/Reconstructive
      • Head and Neck
      • Laryngology
      • Otology/Neurotology
      • Pediatric
      • Rhinology
      • Sleep Medicine
    • Career Development
    • Case of the Month
    • Everyday Ethics
    • Health Policy
    • Legal Matters
    • Letter From the Editor
    • Medical Education
    • Online Exclusives
    • Practice Management
    • Resident Focus
    • Rx: Wellness
    • Special Reports
    • Tech Talk
    • Viewpoint
    • What’s Your O.R. Playlist?
  • Literature Reviews
    • Allergy
    • Facial Plastic/Reconstructive
    • Head and Neck
    • Laryngology
    • Otology/Neurotology
    • Pediatric
    • Rhinology
    • Sleep Medicine
  • Events
    • Featured Events
    • TRIO Meetings
  • Contact Us
    • About Us
    • Editorial Board
    • Triological Society
    • Advertising Staff
    • Subscribe
  • Advertise
    • Place an Ad
    • Classifieds
    • Rate Card
  • Search

New Tool from the Joint Commission to Improve Surgical Consultations

by Susan Kreimer • March 6, 2012

  • Tweet
  • Email
Print-Friendly Version

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.”

You Might Also Like

  • Empathy Training as a Tool to Improve Medical Outcomes
  • Patient Safety Comes First in Clinical Decisions on Second Opinion Consultations
  • SM14: Advances in Otolaryngology Improve Surgical Techniques, Treatment of Common Disorders
  • FDA Seeks to Prevent Surgical Fires
Explore This Issue
March 2012

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.

Pages: 1 2 3 4 5 6 | Single Page

Filed Under: Departments, Health Policy Tagged With: outcomes, patient safety, policy, protocol, risk, surgery, technology, time outsIssue: March 2012

You Might Also Like:

  • Empathy Training as a Tool to Improve Medical Outcomes
  • Patient Safety Comes First in Clinical Decisions on Second Opinion Consultations
  • SM14: Advances in Otolaryngology Improve Surgical Techniques, Treatment of Common Disorders
  • FDA Seeks to Prevent Surgical Fires

The Triological SocietyENTtoday is a publication of The Triological Society.

The Laryngoscope
Ensure you have all the latest research at your fingertips; Subscribe to The Laryngoscope today!

Laryngoscope Investigative Otolaryngology
Open access journal in otolaryngology – head and neck surgery is currently accepting submissions.

Classifieds

View the classified ads »

TRIO Best Practices

View the TRIO Best Practices »

Top Articles for Residents

  • Do Training Programs Give Otolaryngology Residents the Necessary Tools to Do Productive Research?
  • Why More MDs, Medical Residents Are Choosing to Pursue Additional Academic Degrees
  • What Physicians Need to Know about Investing Before Hiring a Financial Advisor
  • Tips to Help You Regain Your Sense of Self
  • Should USMLE Step 1 Change from Numeric Score to Pass/Fail?
  • Popular this Week
  • Most Popular
  • Most Recent
    • The Dramatic Rise in Tongue Tie and Lip Tie Treatment
    • Vertigo in the Elderly: What Does It Mean?
    • Experts Delve into Treatment Options for Laryngopharyngeal Reflux
    • Some Laryngopharyngeal Reflux Resists PPI Treatment
    • New Developments in the Management of Eustachian Tube Dysfunction
    • Vertigo in the Elderly: What Does It Mean?
    • New Developments in the Management of Eustachian Tube Dysfunction
    • Some Laryngopharyngeal Reflux Resists PPI Treatment
    • Eustachian Tuboplasty: A Potential New Option for Chronic Tube Dysfunction and Patulous Disease
    • The Dramatic Rise in Tongue Tie and Lip Tie Treatment
    • Why Virtual Grand Rounds May Be Here to Stay
    • Otolaryngologist Leverages His Love of Pinball into Second Business
    • These New Imaging Advances May Help to Protect Parathyroids
    • Is the Training and Cost of a Fellowship Worth It? Here’s What Otolaryngologists Say
    • Which Otologic Procedures Poses the Greatest Risk of Aerosol Generation?

Polls

Have you used 3D-printed materials in your otolaryngology practice?

View Results

Loading ... Loading ...
  • Polls Archive
  • Home
  • Contact Us
  • Advertise
  • Privacy Policy
  • Terms of Use

Visit: The Triological Society • The Laryngoscope • Laryngoscope Investigative Otolaryngology

Wiley
© 2021 The Triological Society. All Rights Reserved.
ISSN 1559-4939

loading Cancel
Post was not sent - check your email addresses!
Email check failed, please try again
Sorry, your blog cannot share posts by email.
This site uses cookies: Find out more.