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Project slashes risks linked to wrong-site surgery

by Brendon Nafziger, DOTmed News Associate Editor | June 29, 2011
Eight hospitals and surgery centers say a series of process-improvement measures using features from Lean Six Sigma were able to reduce the errors that can lead to surgeons mistakenly performing procedures on the wrong patient or body part.

The project, designed by the Joint Commission, helped cut the number of process defects linked with wrong-site surgeries by as much as half for some parts of the surgical process.

These errors include missing or incorrect patient documents, rushed pre-op preparations and incorrectly marking a patient's body prior to surgery.

"There is no silver bullet or quick fix, but the work of the center is beginning to show even those complex problems that have resisted solution for so long, are being effectively addressed," Dr. Mark R. Chassin, president of the Joint Commission, told reporters on a call Wednesday.

Wrong-site surgery reporting isn't mandatory in most states. But the Joint Commission said according to some estimates, as many as 40 cases a week in the U.S. involve the wrong procedure, wrong patient or wrong side.

Still, it's rare enough that the program, launched by the Joint Commission's Center for Transforming Healthcare in 2009, couldn't tackle wrong-site procedures outright.

"They're so uncommon that an individual surgeon or even a hospital or surgery center may not have experienced one of these events in the recent past," Chassin said.

Instead, the program went after the processes that up the risk of a wrong-site horror.

Getting results

The project involved a mix of five hospitals and three ambulatory surgical centers, which together perform more than 100,000 surgeries a year.

In the program, providers relied on what the Joint Commission calls Robust Process Improvement, which uses Lean Six Sigma and other management techniques, to identify and fix risky areas. And the participating hospitals and centers say it was effective.

For instance, at one site in the project, administrators discovered staff were using unapproved pens to mark patients before surgery, so the mark was washed away during preparation. Now, after the site discovered this problem, only indelible ink is used.

In a slideshow documenting the project, the Joint Commission says the number of cases with defects fell at every stage in the process. For booking, it dropped from 52 percent at baseline to 19 percent after the project started; for pre-op, from 52 percent to 19 percent; and in the OR, from 59 percent to 29 percent.

Also, the number of cases with more than one defect fell by 57 percent for booking, 72 percent for pre-op and 76 percent for the OR.

Started with RI

The project began in July 2009, with two hospitals affiliated with the Lifespan system in Rhode Island, Rhode Island Hospital and Newport Hospital. From 2007 to 2009, Rhode Island Hospital had five wrong-site surgeries, according to WPRI News. In Nov. 2009, it was fined $150,000 for one of those surgeries, in which surgeons began operating on the wrong finger of a patient.

"It's been approximately 20 months without, and I knock on wood every day, without any wrong-site surgery in our ORs," Dr. Mary Reich Cooper, senior vice president and chief quality officer of Lifespan Corp. in Providence, said on the call.

Other health care facilities that participated in the project include AnMed Health in Anderson, S.C.; Center for Health Ambulatory Surgery Center in Peoria, Ill.; Holy Spirit Hospital in Camp Hill, Penn.; La Veta Surgical Center in Orange, Calif.; The Mount Sinai Medical Center in New York; Seven Hills Surgery Center in Henderson, Nev.; and Thomas Jefferson University Hospitals in Philadelphia.

Edgar Hume IV


July 25, 2011 12:54

Have the patient sign on, so long as they are cognizant, or if not their legal representative simply marks the spot that has been agreed upon to be operated upon... People have been writing "Wrong Leg!" on their bodies for years to prevent unnecessary tragedies, simple enough to make this part of the sign on process before something as significant and potentially life altering as surgery!

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