Last week the Joint Commission Center for Transforming Healthcare released detailed solutions for health care providers in reducing the risk of wrong site surgery.
By using certain methods such as Lean Six Sigma (originally a set of practices designed to eliminate defects in the manufacturing process, it has recently been applied in other areas such as health care) and change management to identify the causes of wrong site surgery, the institutions cooperating with the Joint Commission Center identified concerns with scheduling, ineffective communication. and operating room distractions.
Furthermore, the “Time Out” process (occurring prior to the incision, the surgeon calls a “Time Out” so that every member of the surgical team can pause to verify the correct operative site) was only successful when it included all key people in the operating room. The Joint Commission Center also noted:
By reinforcing quality and measurement, emphasizing a culture of safety, strengthening knowledge about wrong site surgery, and improving consistency in surgical processes, the eight participating health care organizations and the Center found that opportunities for errors or defects could be reduced. For example, addressing documentation and verification issues in the pre-op/holding areas decreased defective cases from a baseline of 52 percent to 19 percent. Defects are the causes of and risks for wrong site surgery. In turn, the incidence of cases containing more than one defect decreased 72 percent. The focus on eliminating defects is important because a single operative case has multiple opportunities for defects. When there are multiple defects in a single case, it can further increase the risk of an error reaching the patient. Additionally, it was found that defective cases occurred more frequently when more than one procedure was performed.
Additional information can be found at the Joint Commission Online.