The Joint Commission continues to receive reports of wrong procedure, wrong patient, wrong site, and wrong side operations. Although reporting these events is not mandatory in most states, some estimates put the national incidence rate as high as 40 per week.* Wrong site surgery can have devastating consequences for patients and health care providers, and it can be extremely costly to health care organizations.
To help organizations reduce the occurrence of this type of event, The Joint Commission Center for Transforming Healthcare launched its Targeted Solutions Tool (TST) for Wrong Site Surgery in 2012. This online tool, highlighted in the October 2012 issue of the Bulletin (page 60), guides accredited organizations through a free, step-by-step process to identify, measure, and reduce risks in key processes that may contribute to wrong site surgery.† Over the last three years, the TST has undergone several improvements that have led to better results.
Changes to the TST
To more accurately depict the purpose of the TST, the center renamed it the TST for Safe Surgery in late 2014. The TST for Safe Surgery remains an online application that helps health care institutions evaluate risks across their surgical departments and divisions, including scheduling, preoperative, and operating room (OR) areas. The TST does the following:
- Allows a health care institution to critically assess its entire system of care for operative and interventional procedures, from the time a patient gives consent through the completion of the operation
- Identifies specific risk points in the scheduling of procedures, in preoperative care or services rendered in the preoperative holding area, and in the OR that could potentially lead to a wrong site surgery event
- Standardizes practices and promotes consistency in perioperative processes across multiple physicians and health care professionals within the same organization
- Encourages safe surgery practices that are critical to patient safety
In addition, the TST for Safe Surgery can help organizations determine how well health care professionals are adhering to an existing safe surgery checklist and provide data that can be used to make the checklist more effective.
A useful tool
The TST has proven to be an effective patient safety and quality tool since its launch. The original participating institutions were able to use the TST for Safe Surgery to assess their internal risks for wrong site, wrong side, and wrong patient surgery and then to apply the suggested solutions. On subsequent analysis, these changes led to a reduction of this risk by 46 percent in the scheduling area, 63 percent in the preoperative area, and 51 percent in the OR area.‡
“There are few things that can be more personally devastating to a surgeon than performing an operation on the wrong patient or the wrong site,” said ACS Immediate Past-President Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), The Henry N. Harkins Professor and Chair, department of surgery, University of Washington, Seattle. “Unfortunately, many surgeons do not realize the ease with which a chain of events can be started that can lead to wrong site surgery. Whether it was communication with the scheduler in the clinic, or a wrong click in the computer when selecting a box indicating ‘right’ or ‘left,’ or an X ray that was looked at or interpreted backwards, the event can happen and the only way to avoid the error is to create enough safety barriers to minimize its occurrence. I encourage my colleagues to review the TST for Safe Surgery along with those in their organization that focus their work on patient safety and quality.”
The TST for Safe Surgery is available free of charge to all Joint Commission-accredited institutions, along with the center’s other TSTs for hand hygiene and hand-off communications. In late 2015, the center plans to launch the new TST for Preventing Falls. Learn more about the center.
*Chassin MR, Loeb JM. High-reliability health care: Getting there from here. Milbank Q. 2013;91(3):459-490. Available at: www.jointcommission.org/assets/1/6/Chassin_and_Loeb_0913_final.pdf. Accessed May 1, 2015.
†A look at The Joint Commission: ASCs begin using wrong site surgery tool. Bull Am Coll Surg. 2012;97(10):60. Available at: bulletin.facs.org/2012/10/wrong-site-surgery-tool. Accessed May 29, 2015.
‡The Joint Commission Center for Transforming Healthcare. Safe Surgery Project Fact Sheet. 2014. Available at: www.jointcommission.org/assets/4/6/CTH_SS_Fact_Sheet.pdf. Accessed April 29, 2015.