From the August 2011 issue of HealthCare Business News magazine


Eight U.S. hospitals and ambulatory surgical centers recently teamed up with the Center on the Wrong Site Surgery Project. They used methods such as Lean Six Sigma and change management to discover why these mistakes continue to happen and how they can be stopped. At the end of the project, the groups identified 29 main causes of wrong-site surgeries that occurred during scheduling, in pre-op/holding or in the operating room or which stemmed from the organizational culture.

Two such causes were ineffective communication and distractions in the operating room. Melody Dickerson from the Center says distractions occur much too often.
“Typically, what you’ll see in the operating room is someone reading off the signed surgical schedule and rattling off information while other people in the room are doing work or setting up equipment, but they’re just going through the motions and really aren’t paying attention,” says Dickerson, a Black Belt in the Division of Support Operations who trains Joint Commission staff in Robust Process Improvement, which was used during the project.
She says problems with scheduling and documentation also contribute to costly errors.

“Some of the risk points we found in surgical booking were multiple forms being faxed over two or three times, so the person receiving it doesn’t know if it’s the same form or if there’s been a change because changes were not obviously marked,” explains Dickerson.

Over the course of the Wrong Site Surgery Project, the Center and participating organizations were able to reduce the number of defective cases (defects are the causes of risks that could result in wrong-site surgery) in surgical booking from 39 percent to 21 percent; in pre-op from 52 percent to 19 percent; and in the operating room from 59 percent to 29 percent.

But Dickerson says there’s still work to be done. “When you consider the number of defects that hospitals had before our project, these reductions are certainly a remarkable improvement,” she says. “But of course you would like to get that number down to as close to zero as possible.”

Steps in the right direction
The good news is that some of the solutions provided by the Wrong Site Surgery Project seem simple to put into practice. They require, for example, the doctor to physically mark the site of the surgery during the pre-operative preparation; make both doctors and nurses double-check one another as to the proper site of the surgery; and for physicians to speak with patients in the operating room before surgery begins to verify the patient’s name and what procedure is to be performed.

August 2011 Magazine

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