Wrong site, wrong procedure, and wrong person surgeries (WSS) continue to occur in health care organizations across the U.S. To help avoid these preventable errors, The Joint Commission strongly supports the Association of periOperative Registered Nurses’ (AORN) National Time Out Day on June 11.
National Time Out Day provides a timely opportunity for surgeons and their operating room (OR) teams to review the importance of conducting a safe, effective time out for every patient, every time. In addition, it encourages surgical team members to feel comfortable about speaking up for safe practices in the OR.
Risk factors
Some estimates place the national incidence rate of WSS at as high as 40 to 60 per week, which means that as many as 1,300 to 2,700 incidents occur annually, according to the Joint Commission Center for Transforming Healthcare.
The Center has found that several factors contribute to an increased risk of WSS, including:
- More than one surgeon is involved in the case, either because multiple procedures are contemplated or because the care of the patient is transferred to another surgeon
- Multiple procedures are conducted on the same patient during a single trip to the OR, especially when the procedures are on different sides of the patient
- Time-related issues occur, such as an unusual start time or pressure to speed up the preoperative procedures
- Unusual patient characteristics, such as a physical deformity or massive obesity, that might alter the typical process for equipment setup or positioning of the patient
In these instances, a time out that includes full participation by all OR team members can significantly reduce the risk of WSS.
Universal Protocol
The Joint Commission has long been a proponent of well-executed time outs as part of a multi-layered defense against WSS. In July 2003, The Joint Commission’s Board of Commissioners approved the original Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery for all accredited hospitals, ambulatory care, and office-based surgery facilities.
The Universal Protocol, which became effective July 1, 2004, was developed to address the continuing occurrence of WSS within Joint Commission-accredited health care organizations. It expanded on a series of requirements under the National Patient Safety Goals from 2003 and 2004. The three principal components of the Universal Protocol include:
- Pre-procedure verification
- Site marking
- Time out
In 2010, the Universal Protocol was revised based on feedback from surgeons and other stakeholders. The revision was intended to address patient safety issues while also allowing health care organizations more flexibility in applying the requirements within existing work processes, taking into account the diversity of the health care organizations that need to follow the protocol.
Sentinel event
The Joint Commission has identified WSS as a sentinel event—an unexpected occurrence involving death or serious physical or psychological injury. This type of incident signals the need for immediate investigation, comprehensive analysis, and systematic improvement. It requires a team response that stabilizes the patient, discloses the event to the patient and family, and provides support for the family, as well as for the staff involved in the event. The investigation produces a root-cause analysis that reveals underlying organizational systems and processes that can be altered to reduce the likelihood of such an incident occurring in the future.
The most common root causes of WSS reported to The Joint Commission’s Office of Quality and Patient Safety are ineffective leadership, poor communication, and human factors. Accredited health care organizations are strongly encouraged to voluntarily report WSS as a sentinel event to The Joint Commission. To help health care professionals through this process, The Joint Commission has established a Sentinel Event Hotline at 630-792-3700.
Surgeon involvement
Too often, surgical teams are unsure of what constitutes an effective time out. It is important for surgeons and leaders on the surgical team to consistently model a quality time out, not only on National Time Out Day, but all year long.
Surgeons and their teams should always follow a standardized time out practice to avoid any changes that may weaken the process. When the time out practice is carefully followed, team members should be recognized for supporting patient safety. Recognition may be included in performance evaluations or merit awards.
It also is important for surgeons to watch for any inconsistencies and to listen to concerns expressed by team members. Likewise, surgeons should encourage team members to take the time to listen to patients and their families, and to be on guard for any inconsistencies or other warning flags. The entire surgical team should feel comfortable voicing any and all concerns.
Additional resources
One WSS is one too many. The Joint Commission remains committed to reducing WSS. In February 2012, the Joint Commission Center for Transforming Healthcare launched its Targeted Solutions Tool (TST) for Wrong Site Surgery. The TST serves as a step-by-step guide for accredited health care organizations to identify, measure, and reduce risks in key processes that contribute to WSS.
The TST makes it possible for leaders at health care organizations, including surgeons, to address issues that might result in WSS. It is proven to be effective; use of the TST and implementing improvements reduced the number of cases with risks by 46 percent in the scheduling area, by 63 percent in pre-op, and by 51 percent in the operating room.*
Surgical patients deserve safe surgery. For more information on WSS, visit jointcommission.org or centerfortransforminghealthcare.org.
*The Joint Commission Center for Transforming Healthcare. Targeted Solutions Tool for Wrong Site Surgery. Available at: http://www.centerfortransforminghealthcare.org/tst_wss.aspx. Accessed April 23, 2014.
