Ten years ago my wife was being carted into an OR at outpatient facility in Northern Virginia. The nurse took out a marker and put a big X on her left hip. My wife, who was still alert, said, "Um, that's the wrong side. You're operating on the right side."
"Oh, really," the befuddled nurse responded.
A few moments later, the doctor came by, took the marker from the nurse and crossed out the X. "Oh, don't worry," she said, trying to reassure my now even more nervous wife, "I know which side." She left to go scrub without making a mark on the right side.
Thankfully, the surgery was a success and my wife was home within hours. Still, we were one administered dose of anesthesia away from being victims of a relatively rare—but major—medical mishap.
Wrong-site surgery (which includes wrong-patient, wrong-procedure, wrong-site and wrong-side surgeries) were the third most common sentinel event reported to the Joint Commission in 2010, according to Mark Chassin, M.D., president of the commission. These are errors that "should never occur. These are all preventable," Chassin said during a press call yesterday announcing results from a new project to reduce the risks of wrong-site surgery.
The commission's Center for Transforming Healthcare has been working with eight hospitals to not only assess the risks for wrong-site surgery, but develop targeted and standardized solutions. Chassin said the problem turns out to be far more complex than most people suspect. The eight hospitals found that risks start at scheduling and go all the way through to the OR. For instance, in 39 percent of cases, an error was introduced in booking. That usually meant there was incomplete information in the scheduling documents—missing patient consent forms, missing patient history, missing orders from the surgeon, and so on. Chassin said part of the problem is scheduling usually occurs in a physician's office, not the hospital. Clerical staff in that physician's office may have to deal with multiple hospitals, all with different booking practices. The physician's office itself is likely to have different booking practices. Once targeted solutions were implemented though, the defects dropped to 21 percent. Some of the solutions included simple things like building a relationship with the physician's office to double check and improve the accuracy of the information.
Significant problems were also discovered in the pre-op/holding areas. As in my wife's case, for instance, someone other than the surgeon marks the surgical site. Defects in pre-op ran as high as 52 percent for the eight hospitals, but fell to 19 percent once targeted solutions were implemented.
Mary Reich Cooper, M.D., senior vice president and chief quality officer, at Lifespan Corp., Providence, R.I., said the four-hospital system virtually eliminated defects by changing processes in holding areas. In the past, discrepancies would sometimes arise if the surgeon did not participate in pre-op procedures. "Now, surgeons go out to the holding are to make the initial mark with the patient and the staff," she said during the press call. Everyone affirms that the right mark has been made. Lifespan went so far as to close its ORs for a day to conduct training on this new process. "We audit ourselves everyday for every procedure," she added.
Lifespan actually initiated the project with the center after experiencing five wrong-site surgeries between 2007 and 2009. Since contacting the Joint Commission 20 months ago, Lifespan hasn't had an incident.
"This is one group of problems that are uncommon, but are devastating when they occur," Chassin said, noting that an individual physician or hospital may not have experienced an error and thus may think it can't occur at their institution. Because of that, Chassin said, "we don't measuring the events, we measure the risk of it occurring. It's the measurements that opens eyes."
The center plans to test the targeted solutions with a pilot group of hospitals this summer, with the aim of releasing them to the entire field in the fall. But Chassin said hospitals should not wait to begin addressing the problem. "Unless organizations take a systematic approach to studying the risk of wrong-site surgery, they are flying blind," he said.