What’s New in the Patient Safety World

August 2011

New Wrong-Site Surgery Resources



Most of you by now have probably seen or heard about the Joint Commission Center for Transforming Healthcare’s Wrong Site Surgery Project. This was a collaborative done in conjunction with 8 healthcare systems. They basically identified many of the key factors contributing to cases of wrong-site or wrong-patient surgery, then planned and tested interventions aimed at eliminating or mitigating those factors. They found important factors in scheduling, the pre-op/holding area, the OR itself, and organizational factors that were important contributors to wrong-site surgery. The “fact sheet” they provide lists the contributing factors in each domain along with identified solutions. More importantly, the “storyboards” walk you through the steps they used in each domain, identifying “defective cases” and measuring the improvement over time in the rates of defective cases. This methodology is very important since it is very difficult to measure occurrences of adverse events that are rare, such as cases of wrong-site surgery.


There is also a wrong-site surgery project video on the website, highlighting the fact that we continue to see about 40 cases of wrong-site surgery every week in the US despite tremendous focus on the problem.


These resources should be very valuable to your organizations and the methodology used (called Robust Process Improvement or RPI) is one you can use in other projects aimed at preventing rare adverse events.


Meanwhile, the Veterans Health Administration medical centers reported on progress they have made in reducing incorrect surgical procedures since they implemented a number of patient safety interventions (Neily 2011). The rate of adverse events decreased from 3.21 to 2.4 per month. Meanwhile, the number of close calls increased from 1.97 to 3.24 per month. They attributed the improvement to the increased attention to OR patient safety and their Medical Team Training (MTT) program which improved team communications.


As we’ve recently mentioned, almost 50% of their adverse events in this category actually occurred outside the OR. We’ve long known that wrong-site procedures outside the OR are frequent (in our Patient Safety Tip of the Week November 25, 2008 “Wrong-Site Neurosurgery” we noted that chest tubes inserted on the wrong side was the most frequent wrong-site occurrence in New York State in the past). In our December 6, 2010 Patient Safety Tip of the Week “More Tips to Prevent Wrong-Site Surgery” we noted a study (Stahel 2010) highlighting the continued occurrence of wrong-patient and wrong-site occurrences that had some interesting revelations. The Stahel paper notes how often events such as mislabeling pathology specimens, mixups in medical records or imaging studies or lab reports contributed to the adverse events even inside the OR. That study highlights the importance of the “time-out” in multiple venues of patient care where correct identification of patients and clinical information is critical.


The VA investigators developed multiple lessons learned from root cause analyses of these adverse events. The most common root cause was lack of standardized clinical processes.


The specialties with the highest rates of adverse events were Neurosurgery and Ophthalmology. They noted that Ophthalmology continued to have challenges with wrong implants. We previously addressed similar Ophthalmology issues in our June 5, 2007 Patient Safety Tip of the Week “ Patient Safety in Ambulatoy Surgery” and our March 11, 2008 Patient Safety Tip of the Week “Lessons from Ophthalmology”.




Some of our prior columns related to wrong-site surgery:


Patient Safety Tip of the Week columns:

  September 23, 2008 “Checklists and Wrong Site Surgery

  June 5, 2007 “ Patient Safety in Ambulatoy Surgery

  March 11, 2008 “Lessons from Ophthalmology

  September 14, 2010 “Wrong-Site Craniotomy: Lessons Learned

  November 25, 2008 “Wrong-Site Neurosurgery

  January 19, 2010 “Timeouts and Safe Surgery

  June 8, 2010 “Surgical Safety Checklist for Cataract Surgery

  December 6, 2010 “More Tips to Prevent Wrong-Site Surgery

  June 6, 2011 “Timeouts Outside the OR


What’s New in the Patient Safety World columns:

  July 2007 “Pennsylvania PSA: Preventing Wrong-Site Surgery







Joint Commission Center for Transforming Healthcare. Wrong Site Surgery Project.



fact sheet











Neily J, Mills PD, Eldridge N, et al. Incorrect Surgical Procedures Within and Outside of the Operating Room. A Follow-up Report. Arch Surg 2011; Published online July 18, 2011




Stahel PF, Sabel AL, Victoroff MS, et al. Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era. Analysis of a Prospective Database of Physician Self-reported Occurrences. Arch Surg. 2010; 145(10): 978-984















Tip of the Week Archive


What’s New in the Patient Safety World Archive