August 28, 1998
Since the Joint Commission's Sentinel Event Policy was first introduced two years ago, the Accreditation Committee of the Board of Commissioners has reviewed 15 cases related to surgery at the wrong site (e.g. left leg instead of right. A root cause analysis was completed for each of the events reviewed. Wrong site surgery was most common during orthopedic procedures (10), followed by urologic procedures (3) and neurosurgical procedures (2).
Joint Commission reviewers have identified several factors that may contribute to an increased risk of wrong-site surgery. These risk factors include:
- more than one surgeon involved in the case, either because multiple procedures were contemplated or because the care of the patient was transferred to another surgeon;
- multiple procedures were conducted on the same patient during a single trip to the operating room, especially when the procedures were on different sides of the patient;
- unusual time pressures, related to an unusual start time or pressure to speed up the preoperative procedures;
- and unusual patient characteristics such as physical deformity or massive obesity that might alter the usual process for equipment set-up or positioning of the patient.
The root causes identified by the hospitals most often related to communication, preoperative assessment of the patient, and the procedures used to verify the operative site. Communication issues fall into two categories:
- failure to engage the patient (or family, when appropriate) in the process of identifying the correct surgical site, either during the informed consent process or by the physical act of marking the intended surgical site; and
- Incomplete or inaccurate communication among members of the surgical team, often through exclusion of certain members of the team (e.g. surgical technicians) from participation in the site verification process, or through reliance solely on the surgeon for determining the correct operative site.
The completeness of the preoperative assessment of the patient, was a frequent contributing factor, often through failure to review the medical record or imaging studies in the immediate preoperative period. The procedures for verifying the correct operative site were found to be flawed in many cases due to: no formal procedure;no final check in the operating room; the absence of any oral communication in the verification procedure;all relevant information sources not available in the operating room;no checklist to ensure all relevant information sources were checked;some members of surgical team were excluded from the verification process and felt they were not permitted to point out a possible error; and total reliance on the surgeon for verifying the surgical site, coupled with the attitude that the surgeon should never be questioned.
Suggested Strategies For Reducing The Risk Of Wrong-Site Surgeries
The Joint Commission offers the following strategies for reducing the risk of wrong-site surgery:
- Clearly mark the operative site and involve the patient in the marking process to enhance the reliability of the process.
- Require an oral verification of the correct site in the operating room by each member of the surgical team.
- Develop a verification checklist that includes all documents referencing the intended operative procedure and site, including the medical record, X-rays and other imaging studies and their reports, the informed consent document, the operating room record, and the anesthesia record; and direct observation of the marked operative site on the patient.
Other strategies that may be helpful include:
- personal involvement of the surgeon in obtaining informed consent; and
- ensure through ongoing monitoring that verification procedures are followed for high-risk procedures.