Joint Commission Identifies 29 Main Causes of Wrong-Site Surgery, Offers Solutions

The Joint Commission Center for Transforming Healthcare has identified 29 causes of wrong-site surgery and offered "targeted" solutions for how to overcome these challenges.


The causes and solutions were identified during a wrong-site surgery project that saw eight hospitals and ambulatory surgical centers teaming up with the Joint Commission Center for Transforming Healthcare to improve the safeguards to prevent patients from wrong-site, wrong-side and wrong-patient surgical procedures, according to information from The Joint Commission.


The project was initiated in July 2009 by The Joint Commission Center for Transforming Healthcare and the Lifespan system in Rhode Island, and in 2010, four additional hospitals and three ASCs joined the project.


"Because ambulatory surgery centers represent a unique outpatient care provider model, we are pleased that ASCs were able to participate in this project," said William Prentice, executive director of the Ambulatory Surgery Center Association, according to The Joint Commission. "Although ASCs already report very low incidences of wrong site, side, patient, procedure and implant surgeries, we look forward to learning more about the ways the results of this project can help improve the high quality of care ASCs already provide."


The project aims to address the problem of wrong-site surgery, which is estimated to occur 40 times a week based on state data, using Robust Process Improvement (RPI) methods. RPI is a fact-based, systematic, and data-driven problem-solving methodology incorporating tools and methods from Lean Six Sigma and change management methodologies.


Sign up for our FREE E-Weekly for more coverage like this sent to your inbox!


The Joint Commission is planning to release an electronic Targeted Solutions Tool for the prevention of wrong-site surgery in the fourth quarter of 2011. The tool will be available for use by any Joint Commission-accredited organization. It is currently being tested by half a dozen ASCs.


Here are the 29 main causes of wrong-site surgeries that occurred during scheduling, in pre-op/holding or in the operating room, or which stemmed from the organizational culture, and solutions to these problems, according to The Joint Commission. Note: Some solutions are applicable to numerous causes.





1. Booking documents not verified by office schedulers

Confirm the accuracy of the operating room schedule

2. Schedulers accept verbal requests for surgical bookings instead of written documents

Limit entry points for primary documentation (consent, history and physical, physician orders, booking/scheduling form) to a single fax number

3. Unapproved abbreviations, cross-outs, and illegible handwriting used on booking form

Build on relationships with physician offices to improve the accuracy of information received and methods used to confirm the accuracy of the operating room schedule

4. Missing consent, history and physical, or surgeon's orders at time of booking


Confirm the presence and accuracy of primary documents critical to the verification process prior to the day of surgery (signed surgical consent, history and physical, and physician orders)


Pre-op holding/ holding

5. Primary documents (consent, history and physical, surgeon's booking orders, operating room schedule) missing, inconsistent or incorrect

Share the data and allow the team to ask questions

6. Paperwork problems identified in pre-op but resolved in a different location

Create an environment in which staff are expected to speak up when they have a patient safety concern

7. Inconsistent use of site marking protocol

Examine processes for inconsistencies and seek to understand the cause of variation

8. Someone other than surgeon marks site

Mark in the pre-op/holding area performed by the surgeon using a single-use surgical skin marker with a consistent mark type (e.g., surgeon's initials) placed as close as anatomically possible to the incision site

9. Surgeon does not mark site in pre-op/holding

Mark the site for every procedure; if not possible, document why a sitemark was not performed

10. Site mark made with non-approved surgical site marker

Do not move patient to the operating room before surgeon has marked the site

11. Stickers used in lieu of marking the skin

Provide rationale for changes important to implement even if a wrong site surgery event has not occurred

12. Inconsistent site marks used by physicians

Provide ongoing education and just-in-time coaching

13. Inconsistent or absent Time Out process for regional blocks

Verify all regional blocks using a standardized Time Out process

14. Rushing during patient verification

Describe the rationale to staff for why standardized processes are important

15. Alternate site marking process does not exist or is not used

Confirm identification of patient by all team members using patient armband, patient speak back, or patient caregiver if patient has been sedated

16. Inadequate patient verification by team


Examine processes for inconsistencies and seek to understand the cause of variation


Operating room

17. Lack of intraoperative site verification when multiple procedures performed by the same provider

Perform a pause between each procedure that occurs within a single case to ensure that each procedure is performed accurately and according to the procedure, site and laterality contained within the signed surgical consent

18. Ineffective hand-off communication or briefing process

Perform a pre-operative briefing in the operating room with patient involvement, if possible, to verify patient identity, procedure site and side, along with other critical elements that need to be verified and addressed but are not part of the Time Out process.

19. Primary documentation not used to verify patient, procedure, site and side

Monitor compliance of standardized work processes, tools and methods in all steps of the process (scheduling/booking, pre-op/holding, operating room)

20. Site mark(s) removed during prep or covered by surgical draping

Examine processes for inconsistencies and seek to understand the cause of variation

21. Distractions and rushing during Time Out

• Work with operating room team to develop a role-based Time Out process that works for your organization

• Perform a standardized Time Out process, which occurs after the prep and drape, and includes the following elements:

►Perform role-based Time Out in which every team member has an active role to play in the process

►Point and touch verification of the surgical site mark by the surgeon and scrub technician

►Address any concerns by the team before proceeding

►Reduce noise and cease all other activity in operating room

22. Time Out process occurs before all staff are ready or before prep and drape occurs

Empower all team members to participate in processes designed to reduce the risk of wrong site surgery; everyone is expected to speak up

23. Time Out performed without full participation

• Demonstrate leadership's commitment to implement standardized work processes for all steps – scheduling, pre-op/holding and operating room

• Educate staff by using active learning techniques rather than communicating only through e-mails or posters


24. Time Outs do not occur when there are multiple procedures performed by multiple providers in a single operative case


Separate Time Out for procedures that have a change in surgeon


Organization culture

25. Senior leadership is not actively engaged

Hold all caregivers and staff accountable for their role in risk reduction; organization should define roles

26. Inconsistent organizational focus on patient safety

Utilize an ongoing measurement system for identifying inconsistencies in real time

27. Staff is passive or not empowered to speak up

Share the data and allow the team to ask questions

28. Policy changes made with inadequate or inconsistent staff education

• Utilize a team approach when teaching all staff how the process should be executed

• Celebrate success; everyone should be aware of improvement


29. Marketplace competition and pressure to increase surgical volume leads to shortcuts and variation in practice

Create an environment in which staff are expected to speak up when they have a patient safety concern


Learn more about the wrong-site surgery project from The Joint Commission Center for Transforming Healthcare.


More Articles Featuring The Joint Commission:

4 Mistakes to Avoid When Applying for Accreditation

Joint Commission Publishes 'Do Not Use' List Fact Sheet

Joint Commission Releases Fourth Animated Patient Safety Video, Focuses on Doctor's Office Appointments

Copyright © 2024 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.


Featured Webinars

Featured Whitepapers

Featured Podcast