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Bathla S, Chadwick M, Nevins EJ, et al. J Patient Saf. 2021;17:e503-e508.
Wrong-site surgery represents a never event. In the United States, The Joint Commission requires marking of the surgical site prior to surgery as part of the Universal Protocol. Researchers conducted a survey study of 120 surgeons in the United Kingdom and found significant variation in adherence to the national mandate for preoperative surgical site-marking.
Joint Commission.
The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality improvement (QI) in areas related to its accreditation functions. In the first major initiative under the leadership of new president Dr. Mark Chassin, The Joint Commission launched this Center, which will focus on applying rigorous QI methods to improve safety in a number of challenging areas (the first three are hand hygiene, handoff communication, and preventing wrong site surgery) and disseminating the lessons from these efforts. This Web site provides more information about the Center and its goals.
Rhodes P, Giles SJ, Cook GA, et al. Qual Saf Health Care. 2008;17:409-15.
Wrong-site surgery is a rare yet devastating outcome. Prevention strategies have focused on adoption of the Joint Commission's Universal Protocol and structured communication tools such as time outs. This study examined the impact of a national safety alert issued to all NHS hospital trusts in England and Wales about preventing wrong-site surgery. Investigators interviewed surgeons and senior nurses in the 12-15 months following the alert and discovered significant variation in the adoption of proposed recommendations. While the alert was associated with greater awareness and surgical marking of sites, the authors discuss the complex nature of change management around the new policy. A related commentary [see link below] discusses the broader context of efforts to eliminate wrong-site surgery. A past AHRQ WebM&M commentary discussed the factors contributing to a near-miss wrong-site surgery, and a recent commentary outlined the anatomy of a time out.
Michaels RK, Makary MA, Dahab Y, et al. Ann Surg. 2007;245:526-32.
Wrong site operations are rare and often occur when systems to prevent them fail. This study reviewed existing prevention strategies, such as the Joint Commission's Universal Protocol, to develop a framework for hospitals to assess their wrong site event prevention efforts. The proposed framework asks whether a behaviorally specific policy has been enacted and whether staff understand the policy, and goes on to recommend directly observing the policy being put into practice. The authors advocate standardized interventions utilizing effective methods to measure safety. A previous Agency for Healthcare Research and Quality (AHRQ) WebM&M commentary discusses factors that place patients at risk for wrong site surgery.
St Paul, MN: Minnesota Department of Health.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2020 report summarizes information about 366 adverse events that were reported, representing a slight increase each year since the reports were first published. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.