ASCs begin using wrong site surgery tool

Wrong site surgery is considered a rare event; however, some estimates put the national rate as high as 40 per week. The costs are many, including the loss of public trust and the threat of malpractice suits that can result in multi-million dollar judgments. For Joint Commission-accredited ambulatory surgery centers (ASCs), tested wrong site surgery solutions are now available and used in real-world situations.

The Joint Commission Center for Transforming Healthcare’s Targeted Solutions Tool™ (TST) guides ASCs through a no-cost, step-by-step process to identify, measure, and reduce risks in key processes that can contribute to a wrong site surgery.

Rather than a checklist or bundle, the Web-based application uses a six-step process to help organizations measure their performance in the areas of surgical booking, preop/holding, and the operating room. The TST analyzes these data, places the results into a presentation-ready format, and leads an organization to solutions targeted to address the risks that emerged from the data analysis, according to Andrew Ward, MD, the medical director of Algonquin Road Surgery Center, Lake in the Hills, IL—a surgery center that uses TST.

“After having implemented the tool, we’ve gained the acceptance and the buy-in from the surgeons, the staff, and the anesthesiologists to increase our percentage and get close to 100 percent compliance in the operating room and to drastically improve the compliance in the holding room,” said Dr. Ward.

The TST provides training tools and resources to prepare select staff members to collect observation data. Observations can be collected on paper forms or input directly into the TST using a tablet device, such as an iPad. Data collection is critical to the project since the focus of improvement stems from the data. Organizations may begin to experience improvements in as little as eight weeks, with most organizations completing the project—and seeing results—in 14 to 16 weeks.

Among the resources provided in the TST are training modules, which include videos showing examples of both good and bad practices. There are also interactive training materials that assess staff learning. A benefit is the TST’s ability to provide advanced data analysis and automatically generate charts and graphs that represent organizational performance. This feature allows easy sharing of data and performance charts with leadership and staff.

“The biggest improvement we’ve seen in using the wrong site surgery tool is that we’ve gotten a buy-in from the staff and surgeons at the beginning of cases. Previous to using the tool we would have people working on the Mayo stand, checking gauges, writing things down, and not really paying attention to the time outs. Now, however, everybody does stop, everyone listens, and everyone agrees,” said Dr. Ward.

For more information about the wrong site surgery project and the TST, visit the Joint Commission Center for Transforming Healthcare website at, call 630-792-5800, or e-mail

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