Joint Commission case example addresses wrong site surgery

A new educational tool from The Joint Commission provides details on how to identify risk factors and possibly improve processes related to wrong site surgery.

The free resource—Case example #2: Patient undergoes additional procedure after wrong lung biopsy—is a fictionalized case example.* The study is an amalgamation of conditions all too commonly implicated as contributing factors in safety events reported to The Joint Commission’s Office of Quality and Patient Safety. The details in this case study help to illustrate common breakdowns and failure points that Joint Commission staff have found are associated with wrong site procedures, though such factors (including insufficient resources, poor communication and teamwork, and unprofessional behavior) are associated with a variety of adverse incidents.

Case example #2

The case example lays out a situation in which a patient was scheduled for a transbronchial biopsy of the right upper lung to obtain specimens and determine whether a lung mass was malignant. The patient consented to a bronchoscopy using fluoroscopic guidance.

According to the case example, the procedure—which was scheduled to be the first case of the morning—was delayed an hour because another physician needed to use the endoscopy suite. The nurse completed the preoperative evaulation, and when the endoscopy suite became available, other cases began to stack up. As a result, the team felt a sense of urgency to complete the procedure quickly.

The circulating nurse set up the C-arm and laterality of images while the diagnostic radiology technician (DRT) in the next room assisted with the completion of another procedure. The images showed left-side laterality in error.

After the room was prepared, the pulmonologist entered the room and a time-out was performed. Though the correct laterality was noted on the whiteboard in the room, confirmation of laterality was not communicated during the time-out process because the consent for “bronchoscopy using fluoroscopic guidance” did not address the laterality. The pulmonologist inserted the scope into the left lung to obtain biopsy specimens. The DRT entered the suite to assist with fluoroscopy. When the pulmonologist noted the completion of the left lung specimen collection, the DRT did not inform the pulmonologist of the discrepancy with the whiteboard. The technician assumed it was the correct site because the images aligned with the pulmonologist’s communicated location and no one else appeared concerned. Everyone had concentrated on the task they were supposed to complete and had, they thought, done so without error.

During the postprocedure debrief within the operating room, it was discovered that the wrong lung had been entered. The patient was repositioned, and the correct specimens were obtained.


One of the goals of creating these case studies is to provide situations to which many health care professionals can easily relate. The creators also anticipate that users of the resources will ask themselves some questions, such as the following:

  • What are our risk points?
  • How could this error have been prevented?
  • How could this error have been mitigated?
  • Where can we improve in our own system?

The systems-based solutions provided within the case study serve as examples for readers to consider integrating with their improvement endeavors. The case study also helps to raise situational awareness of some common risk points—as well as meaningful strategies to mitigate risk.

Whether in smaller improvement projects or more robust proactive risk assessments, health care professionals can use this tool to proactively evaluate their own processes and promote conditions that support the delivery of safe patient care.

Using the resources

These resources can be downloaded and used in a variety of ways, including the following:

  • Posted on a bulletin board in a staff lounge or break room
  • Discussed during quality and safety meetings
  • Used during training or rounding of similar cases

Case example #2 is available as a downloadable PDF, as is case example #1, which focused on a patient death resulting from failure to rescue.

Look for future case examples in this column that could be beneficial to surgical team members. The case examples present opportunities to improve teamwork, develop better communication skills, and nurture safety culture concepts.


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

*The Joint Commission. Case example #2: Patient undergoes additional procedure after wrong lung biopsy. Available at: Accessed November 26, 2018.


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