Cases & Commentaries

Mark My Limb

Commentary By Dennis S. O'Leary, MD; William E. Jacott, MD

The Case

A patient went to the operating room (OR) for
surgery on the lower leg. Per the Universal Protocol, the surgeon
marked the proper leg prior to bringing the patient to the OR. The
patient was placed in the prone position and anesthesia was
administered. A "Time Out" was performed, during which all the team
members met and confirmed the procedure. The nurse began to prep
the patient's lower leg, but the anesthesiologist felt that
something wasn't right. After stabilizing the patient, he checked
the chart and discovered that the nurse had scrubbed the wrong
extremity. He notified the team members and stopped the procedure.
The patient had come just minutes away from having surgery on the
wrong leg, but no harm occurred. The correct leg was then prepared,
and the patient underwent successful surgery.

The Commentary

Nothing, it is said, is simple. Since 1998, when
the Joint Commission issued its first Sentinel Event Alert on
wrong-site surgery (1,2),
it has amassed over 300 voluntarily submitted reports that describe
the performance of surgical procedures on the wrong body site
(usually right versus left mistakes) or on the wrong patient, or
the performance of the wrong procedure on the "correct"
Some of these occurrences have eventually led to patient deaths.
How—in the world's most sophisticated operating theaters and
in the hands of highly trained surgeons—can such things
happen? Or, in this case, almost happen?

On the surface, the problem in this case is that
the "Time Out" provision in the Universal Protocol was not properly
followed. The Joint Commission's Universal Protocol for the
Prevention of Wrong Site, Wrong Procedure, and Wrong Patient
Surgery was implemented on July 1, 2004 with the formal endorsement
of over 50 surgical specialty societies and other professional
organizations.(4) The
Protocol describes specific requirements for a pre-operative
verification process, the marking of the surgical site, and the
conduct of a "Time Out" in the operating room before the surgical
procedure actually begins.

The basic purpose of the "Time Out" process is
confirmation, but that confirmation, as stipulated in the Universal
Protocol, is multi-faceted. The process is designed so that, at its
conclusion, all of the surgical, anesthesia and nursing
professionals to be involved in the surgical event have
unequivocally confirmed the identity of the patient, the procedure
to be performed, the surgical site, the positioning of the patient
on the operating room table, and, where relevant, the prosthesis to
be implanted. To all appearances in this case, this confirmation
process was not systematically performed.

The preparation for and performance of surgery
are system-dependent processes. This is not—as most medical
students and surgical residents are taught—simply an
engagement between a doctor and his or her patient. From the time
of the decision to perform surgery to transfer of the patient from
the operating room to the post-anesthesia recovery room, multiple,
seemingly simple processes—involving doctors, nurses,
technicians, and other hospital or surgery center staff, as well as
technology of various levels of complexity—become part of the
patient's experience. In health care, we call these "systems." But
in most medical and nursing schools, we do not call these anything,
for systems thinking is not taught in these schools. Nor is much
taught about the importance of teaming (such as Crew Resource
Management principles) and human factors. And
the level of enlightenment on these deserts of knowledge is
unlikely to expand during post-graduate training, particularly when
the teachers and role models lack the relevant training and
understanding themselves.

It is no small wonder that many who labor in
operating rooms believe that wrong-site surgery is something that
happens somewhere else, but certainly never here. Yet every step in
this system—every step that brings the patient to and through
the operating room—is an opportunity for error. And every
human—including every surgeon, anesthesia professional, and
technician—is prone to error. Even if these professionals are
not steeped in systems thinking, basic awareness of the potential
frailties in human performance should breed professional

Good systems do not just happen. They are
carefully designed to involve only steps that are absolutely
necessary, and to include safeguards that will prevent human error
from reaching the patient. Most systems, even simple ones,
operating in health care organizations today fall short of this

The Joint Commission does not operate health care
organizations, nor does it design organization systems. But its
standards, its national patient safety goals (5), and now its surgery Universal Protocol do provide
both general and prescriptive guidance as to how specific
organization systems should be designed. Prescriptive guidance is
generally reserved for clearly documented, ubiquitous performance
problems such as medication errors and wrong-site surgery.

These guideposts, and indeed the accreditation
process itself, are intended to help health care organizations and
practitioners do their daily work better. For those who recognize
Joint Commission accreditation and standards as being inseparable
from their daily work, the embracing of the Universal Protocol and
other Joint Commission expectations comes quite naturally. For the
remainder, these are often viewed as annoying requirements and
their validity is frequently called into question. In the latter
circumstance, the Universal Protocol is seen as simply another
piece of paper.

Good organization systems are designed by and
"owned" by organizations themselves. Each step in each process is
clearly delineated and understood by all participants, and the
roles of each participant are also well defined. There is no
ambiguity. Here, the Universal Protocol frames the system
expectations, and the organization designs the system(s) to fit its
own particular setting and characteristics.

Today, the Universal Protocol and the specific
internal systems that are based on it, or are otherwise consistent
with it, are "owned" by a growing number of health care
organizations and practitioners. These are organizations in which
the priority for patient safety is progressively becoming an
integral part of their cultures. Indeed, it is the transition to
true cultures of safety across all health care organizations that
will ultimately determine the impact and success of the Universal
Protocol and other efforts to reduce or even eliminate preventable
adverse events.

S. O'Leary, MD
President, Joint Commission on Accreditation of Healthcare

E. Jacott, MD
Special Advisor for Professional Relations, Joint Commission on
Accreditation of Healthcare Organizations
Emeritus Professor of Family Medicine, University of Minnesota
Medical School


1. Sentinel event alert. Lessons learned: wrong
site surgery. Joint Commission on Accreditation of Healthcare
Organizations Web site. August 28, 1998. Available at:
[ go to related site ]. Accessed December 16,

2. Sentinel event alert. A follow-up review of
wrong site surgery. Joint Commission on Accreditation of Healthcare
Organizations Web site. December 5, 2001. Available at:
[ go to related site ]. Accessed December 16,

3. Chassin MR, Becher EC. The wrong patient. Ann
Intern Med. 2002;136:826-33.[ go to PubMed ]

4. Universal protocol for preventing wrong site,
wrong procedure, wrong person surgery. Joint Commission on
Accreditation of Healthcare Organizations Web site. Available
[ go to related site ]. Accessed December 16,

5. 2004 national patient safety goals. Joint
Commission on Accreditation of Healthcare Organizations Web site.
Available at:
[ go to related site ]. Accessed December 16,