Quality professionals must take lead to eliminate wrong-site surgery
Joint Commission continues to push issue in latest alert
Quality professionals must take the lead on the issue of "wrong-site" surgery, an egregious mistake in which the surgical team operates on the wrong part of the body or the wrong patient, or performs the wrong procedure. That’s the message from the Joint Commission on Accreditation of Healthcare Organizations and others who say these problems are continuing despite previous attempts to curb them.
The Joint Commission recently issued a special alert about wrong-site surgery, the second in three years. In the first alert, the Joint Commission and surgical groups urged physicians to pay special attention to this problem and take corrective steps. This time, the Joint Commission seems exasperated that it has to address the issue again.
In announcing the alert, Dennis S. O’Leary, MD, Joint Commission president, called on the health care community to take specific safety steps and sought to enlist patients’ help. "Health care experts are unanimous in their belief that these types of errors should never happen," O’Leary says. "The know-how to create systems that prevent wrong-site surgeries has existed for years, yet the number of errors has not decreased. Even one wrong-site surgery is one too many."
Too many health care professionals see wrong-site surgery as more of a risk management issue than a quality concern, says Nancy Y. Carter, RN, MBA, director of clinical resource management for the Emory Hospitals of Atlanta. Because these mistakes are seen as so outlandish, health care providers often think little can be done to prevent them.
"I think one thing the Joint Commission is telling us is that that attitude should change," she says. "We need to take this issue out of the risk management box and put it in the quality area. We need to be more proactive. Most of us have only seen wrong-site surgery come out of lawsuits, and then you deal with it at that point. But that’s all on the back end."
To solve the problem, quality professionals will need to integrate wrong-site surgery into their quality improvement efforts and stop considering it just a fluke or gross incompetence. In most cases, Carter says, wrong-site surgery involves competent staff and physicians who were tripped up by a flaw in the system. That’s a classic example of where quality professionals can come to the rescue, Carter says.
The first place to look for possible improvements is the advice offered by the Joint Commission. Carter points out that the agency’s advice is based on the root-cause analyses of previous incidents, so it focuses on systemic improvements.
A big part of the solution, O’Leary says, is the practice that has come to be known as "signing your site." The Joint Commission, along with surgical organizations, recommended this practice three years ago and still says it could eliminate most of the errors. In this quality improvement step, physicians place their initials on the surgical site with a permanent marking pen in a way that cannot be overlooked and then actually operate through or next to the initials.
The American Academy of Orthopaedic Surgeons (AAOS) in Rosemont, IL, recommends initials, but some say a complete signature is more easily recognized by the surgeon and others, whereas initials could be confused. An "X" is never a good idea. Does an "X" mean "X marks the spot" or "not here"?
Some surgeons and quality experts have recommended that the surgeon go a step further and mark both appendages, if the surgery is to be done on an arm or leg. By marking one knee "yes" and one knee "no," for instance, the surgeon can get in the habit of always cutting through the yes. When only the "yes" knee is marked, it is still possible for the surgeon to enter the operating room (OR) and find a knee draped and ready but without anything written on it.
The surgeon can mistakenly assume that he or she did not sign the knee and proceed on the wrong appendage, whereas a "no" clearly would indicate the error.
Just as it did three years ago, the American College of Surgeons (ACS) in Chicago joined with the AAOS and the Joint Commission again to recommend that hospitals improve their procedures. In addition to signing the site, they make these recommendations:
• Orally verify the surgery. In the OR just before starting the operation, each member of the surgical team should confirm that they have the correct patient, the correct surgical site, and the correct procedure.
• Take a "timeout" in the OR. This gives the surgical team one last chance to double-check among themselves about the impending procedure, check charts, and corroborate information with the patient. (For more advice, see "Controls may make wrong-site surgery almost impossible," in this issue.)
Communication is key to avoiding blunders
Many cases of wrong-site surgery can be traced to a breakdown in communication, says Tom Russell, MD, executive director of the ACS. Without a good process for double-checking and triple-checking before a scalpel touches skin, one wrong assumption can be carried through by other clinicians, and before you know it, you’ve amputated the wrong leg.
"It is most important that there be cooperative openness between the surgeon and the nurses," he says. "The two groups must both take responsibility, and if there are questions, they should stop to be sure everyone is on the same page. No one should make assumptions."
Wrong-site surgery is a major concern because the effects can be so devastating to the patient, O’Leary says. The incidents also tend to get a lot of media attention, which undermines public confidence in the health care community. And he points out that the Joint Commission’s error reporting database includes more than 150 such cases collected since 1996. In addition to the Joint Commission’s special alerts about the problem, the AAOS and the New York State Department of Health also have independently issued recent recommendations on prevention of wrong site surgeries.
Don’t assume that your hospital’s surgeons know all of this information and already are addressing wrong-site surgery. Chances are good that they haven’t taken any special steps and will need a quality professional to lead them. At Campbell Clinic in Germantown, TN, all 30 orthopedic surgeons and 32 residents sign their patients before surgery, but that’s because S. Terry Canale, MD, the chief of staff, is the past president of AAOS and spearheads its campaign against wrong-site surgery. AAOS research suggests that about half of orthopedic surgeons routinely sign the surgical site.
Surgeons should be encouraged to sign the surgical site at the time they visit with the patient before surgery, possibly the night before or first thing on the day of surgery, he says. Most patients love the idea because they have heard the horror stories about wrong-site surgery and don’t want it to happen to them.
Canale cautions that the act of signing the body part doesn’t help at all if the surgeon did not actually confirm the surgery location. The real benefit from the signing, Canale says, is that the surgeon has taken personal responsibility, before the patient is prepared and draped, for confirming the correct site. The act of signing requires the surgeon to confirm the site personally instead of assuming that the patient is draped correctly.
Wrong-site surgery has been an automatic sentinel event for years, but that hasn’t prompted quality professionals to act. To put some bite in its bark, the Joint Commission is warning that surveyors will check for evidence that accredited facilities are working to prevent wrong-site surgeries.
"But I would hope you don’t do it just for surveys," Carter says. "This is important, whether or not the Joint Commission pushes it. We need to do it whether it’s time for a survey or not."
The new warning about surgical mistakes is the latest in a series of patient safety alerts issued by the Joint Commission. Previous alerts have focused on deadly medication mix-ups, patient suicides, infant abductions, and fatal falls among the elderly. In August 1998, the Joint Commission issued a Sentinel Event Alert examining the problem of wrong-site surgery, including a review of 15 cases.
The Joint Commission is not the only regulatory body coming down hard on wrong-site surgery. In Florida, the Board of Medicine in June 2001 instituted stiff penalties for physicians and organizations experiencing wrong-site surgery. Penalties include fines up to $10,000, five hours of risk management education, 50 hours of community service, and a one-hour lecture to the medical community on wrong-site surgery.
Of the 150 wrong-site surgeries reported to the Joint Commission, 126 have root-cause analysis information. Of the 126 cases, 41% relate to orthopedic/podiatric surgery; 20% relate to general surgery; 14% to neurosurgery; 11% to urologic surgery; and the remaining to dental/oral maxillofacial, cardiovascular-thoracic, ear-nose-throat, and ophthalmologic surgery. Fifty-eight percent of the cases occurred in either a hospital-based ambulatory surgery unit or freestanding ambulatory setting, with 29% occurring in the inpatient OR and 13% in other inpatient sites, such as the emergency department or the intensive care unit.
Seventy-six percent involved surgery on the wrong body part or site; 13% involved surgery on the wrong patient; and 11% involved the wrong surgical procedure.
Eighty-one percent of the cases were self-reported, with the remaining cases coming from patient complaints, media stories, and other sources. However, wrong-site surgery data collected by other organizations, including the New York Department of Health and the Board of Medicine in Florida, suggest a significant amount of underreporting to the Joint Commission by health care organizations.
Most organizations reporting wrong-site surgery cases to the Joint Commission indicated they were aware of the previous Sentinel Event Alert recommendations.
The Joint Commission identified a number of factors contributing to the increased risk for wrong-site, wrong-person, or wrong-procedure surgery, including:
- emergency cases (19%);
- unusual physical characteristics, including morbid obesity or physical deformity (16%);
- unusual time pressures to start or complete the procedure (13%);
- unusual equipment or setup in the OR (13%);
- multiple surgeons involved in the case (13%);
- multiple procedures being performed during a single surgical visit (10%).
The root causes identified by the hospitals usually involved more than one factor; however, the majority involved a breakdown in communication between surgical team members and the patient and family. Other contributing causes included: policy issues such as marking of the surgical site was not required; verification in the operating room and a verification checklist were not required; and patient assessment was incomplete, including an incomplete preoperative assessment. Staffing issues, distraction factors, availability of pertinent information in the OR, and organizational cultural issues also were cited as contributing risk factors.
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