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Joint Commission Unveils Wrong Site Surgery Prevention Tool

Cheryl Clark, for HealthLeaders Media, July 5, 2011

With wrong-site surgeries occurring an estimated 40 times a week in the U.S., the Joint Commission teamed up with several hospitals to nail down precisely where and how these mistakes keep happening.

Now it has a tool that it says can help hospitals discover the flaws in their processes that can lead to irreversible or life-threatening mistakes.

"The Joint Commission has been at the forefront of the wrong site surgery problem for many years," said Mark Chassin, MD, Commission president said at a news briefing Wednesday. "Despite these efforts, the problem remains a significant one. In 2010, wrong site surgery was the third most common sentinel event reported" and it was the most common sentinel event reported between 2004 and 2010.

With the Joint Commission's Targeted Solutions Tool, which uses Robust Process Improvement methods, hospitals and surgical centers "will be able to follow some very simple sets of instructions with an electronic application available through every organization's secure electronic connection with the Joint Commission, Chassin explained. The tool measures each organization's risk "at the time of scheduling, in the pre-op area, and in the operating room."

Recommended checkpoints to eliminate these adverse events are being piloted tested by the eight participating hospitals and are expected to be added to the tool late this summer, the commission announced. Then they will be pilot tested to prove their effectiveness in different types and sizes of hospitals as well as ambulatory surgery centers and other care settings.

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3 comments on "Joint Commission Unveils Wrong Site Surgery Prevention Tool"


Deb Moengen (10/9/2011 at 2:37 PM)
Is the targeted tool material available yet?

Hazem Mohandes (7/9/2011 at 11:41 AM)
Al-thought the article didn't actually go deep into what these strategies are, it's a very informative one. I believe also that strict adherence to the practice of time out would be a key tool and last line of defense in preventing such incidences.

Michael Edwards (7/8/2011 at 2:27 PM)
Dear Sir, At wikisurgery.com, the online surgical encyclopedia, we are very aware of the risks of operating on the wrong patient, the wrong limb and the wrong digit. We have developed a check list that should reduce such risks. It goes into detail that has not been used before. For instance, your studies point out the problems of using a skin pencil that will wash off with the skin prep. We point this out on our website and also indentify a skin marker that is safe. Have a look at http://www.wikisurgery.com/index.php?title=Patient_checks for this and other examples. We would be delighted to link wiksiurgery information to your organisation. Please drop us an email. Best wishes, Michael Edwards FRCS Web Editor Wikisurgery London UK