Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center

Although rare and difficult to study, wrong-site surgery is a serious risk recognized by health care organizations. Health care organizations in a variety of settings must manage the risks of wrong-site surgery to ensure the safety of patients. Preventing wrong-site surgery—which includes wrong-patient, wrong-procedure and wrong-side surgeries—is accomplished by creating a culture of safety and improving perioperative processes.

As part of the Joint Commission Center for Transforming Healthcare wrong-site surgery project, eight U.S. hospitals and ambulatory surgery centers measured the risk of wrong-site surgery in their perioperative processes, pinpointed the contributing causes and developed specific solutions targeted to each one. As a result, the health care organizations significantly reduced the number of surgical cases with risks for wrong-site surgery in four main areas: scheduling, pre-op/holding, operating room and organizational culture. Additional hospitals and ambulatory surgery centers that tested the work of the original organizations experienced the same improved results.

The provider organziations are:

• AnMed Health, Anderson, S.C.
• Center for Health Ambulatory Surgery Center, Peoria, Ill.
• Holy Spirit Hospital, Harrisburg, Pa.
• La Veta Surgical Center, Orange, Calif.
• Mount Sinai Medical Center, New York, N.Y.
• Rhode Island Hospital, Providence, R.I.
• Seven Hills Surgery Center, Henderson, Nev.
• Thomas Jefferson University Hospital, Philadelphia, Pa.

This report describes the types of risks for wrong-site surgery, their root causes and targeted solutions.