JCAHO to ask about wrong-site surgeries
JCAHO to ask about wrong-site surgeries
Surgery mistakes on the rise; most are outpatient
With the number of wrong-site surgeries on the rise, the Joint Commission on Accreditation of Healthcare Organizations has warned that surveyors will ask providers what they are doing to protect patients from wrong-site surgeries. States also are getting involved in the issue of wrong-site surgery. In 2001, the Tallahassee-based Board of Medicine in Florida instituted fines of up to $10,000 for physicians and facilities experiencing wrong-site surgery. Florida’s new rules on wrong-site surgery also require five hours of risk management education, 50 hours of community service, and a one-hour lecture to the medical community on wrong-site surgery when there is an incident.
Also in 2001, the Albany-based New York State Department of Health released steps for preventing wrong-site surgery, wrong procedures, and procedures on the wrong patient. (See "Preoperative Protocols" in this issue.) The Joint Commission reports that the guidelines are considered "baselines" that hospitals, surgery centers, and physicians can build upon and tailor to their settings.
The reason for increased attention at the state and national level is that the number of wrong-site surgeries is increasing. At press time, the Joint Commission said that 58 cases of wrong-site surgery had been reported in 2001, which was up from 16 cases in 1995.
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The increase is backed by research conducted by Eric Meinberg, MD, chief resident at the University of Cincinnati Medical Center, who reported on wrong-site surgery at the 2001 meeting of the Rosemont, IL-based American Society for Surgery of the Hand. Meinberg’s survey of members of the society had 1,050 responses, and 201 (19%) reported performing wrong-site surgery at least once.1
In a recent Sentinel Event Alert, the Joint Commission looked at 126 wrong-site cases in its database that have had a root-cause analysis and found that 58% of the cases took place in an outpatient setting. (For an update on the alerts, see "Joint Commission stops scoring Alert compliance" in this issue.) Meinberg says, "With decreases in reimbursement and the increases in efficiency, speed, and volume that hospitals and physicians are seeing, there are more opportunities to rush and not be as thorough with checks and balances they may have in effect."
In the Sentinel Event Alert, the Joint Commission identified several factors that increased the 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 operating room (13%);
- multiple surgeons involved in the case (13%);
- multiple procedures being performed during a single surgical visit (10%).
According to the Joint Commission, other contributing causes included policy issues such as no requirement for marking the surgical site; no requirement for verification in the operating room (OR) or a verification checklist; incomplete patient assessment, including an incomplete preoperative assessment; staffing; distraction; unavailability of pertinent information in the OR; and organizational cultural issues (such as not designing surgical procedures so they are as safest as they can be). The root causes identified by the hospitals usually involved more than one factor, according to the Joint Commission; however, most involved a breakdown in communication between members of the surgical team and the patient and family.
Consider these suggestions for reducing the risk of wrong-site surgery:
• Have each member of the surgical team orally verify the surgery. The Joint Commission suggests that in the OR, just before starting the operation, all members of the surgical team should confirm that they have the correct patient, the correct surgical site, and the correct procedure. Also, members of the surgical team should check charts and corroborate information with the patient, the Joint Commission says.
• Have surgeons sign the operative site. University of Cincinnati Medical Center implemented a policy in 2001 in which surgeons sign the operative site before the patient is released from the preoperative holding area, Meinberg says. "Other operative checks, such as checking X-rays and operative notes, are still susceptible to error when it comes to the surgical site," he says. "Discussing it with the patient, and having surgeons or the patient marking the site, is truly the only fail-safe way. Anything else falls short of that absolute."
Doctors should place their initials on the surgical site with a permanent marking pen in a way that cannot be overlooked and then operate through or next to the initials, the Joint Commission suggests. In fact, the Joint Commission has suggested that patients should ask their surgeons to mark the site."
"This simple step really will help," says Dennis O’Leary, MD, president of the Joint Commission. "And it is an important way in which patients can play an active role in improving safety."
Reference
1. Meinberg E, Stern P. Incidence of wrong site surgery among hand surgeons. Presented at the 56th Annual Meeting of the American Society for Surgery of the Hand. Baltimore; October 2001.
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