New Tool Helps Prevent Wrong Site Surgeries

The Joint Commission Center for Transforming Healthcare released the Targeted Solutions Tool on Feb. 14 to help accredited organizations install a process for curbing these errors.

The Joint Commission Center for Transforming Healthcare announced what it called "a new weapon in the critical fight to reduce the incidence of wrong site surgery" on Feb. 14. The Targeted Solutions Tool™ (TST) is free to accredited organizations and will help them install a step-by-step process to identify, measure, and reduce risks in key processes that can contribute to a wrong-site surgery, according to the commission. "Although reporting is not mandatory in most states, some estimates put the national incidence rate, which includes wrong patient, wrong procedure, wrong site, and wrong side surgeries, as high as 40 per week," its announcement said.

Six hospitals and ambulatory surgical centers served as pilot test sites.

"Wrong site surgery is a rare event for individual surgeons or health care organizations. But when it does happen, it is a devastating event that is often life-altering for the patient who experiences it. We know wrong site surgery should never happen, but the problem persists," said Dr. Mark R. Chassin, M.D., FACP, M.P.P., MPH, president of The Joint Commission. "Reducing the risk of wrong site, wrong procedure, and wrong patient surgery is critical to patient safety and the reputation of any health care organization that performs invasive procedures. The Targeted Solutions Tool offers organizations a straightforward approach to identifying and eliminating risks of wrong site surgery in all phases of the process of surgery, from scheduling to the operating room."

The tool helps an organization monitor its surgical cases for potential weaknesses that might cause a wrong site surgery, according to the center. Its wrong site surgery project began in July 2009 with eight U.S. hospitals and ambulatory surgical centers involved, using Robust Process Improvement™ (RPI) methodology that involves elements of Lean Six Sigma and change management.

The eight organizations reduced their surgical cases with risks by 46 percent in the scheduling area, by 63 percent in pre-op, and by 51 percent in the operating room, and the pilot test organizations experienced the same gains, according to the center.

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