Sign on dotted arm: How to suture right site

Joint Commission uses public pressure as prescription to cut down on wrong-site surgeries.

By Andis Robeznieks, amednews staff. Jan. 7, 2002.

In the three years since the Joint Commission on Accreditation of Healthcare Organizations issued an alert warning physicians about "wrong-site surgeries" the problem has gotten worse, prompting the issuance of another alert.

The Joint Commission reports 150 instances of physicians working on the wrong side of a patient's body, performing the wrong procedure or operating on the wrong patient since 1995, with the number increasing every year since 1997. Fifty wrong-site surgeries were reported in 2000 and at least 58 in 2001.

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Although the numbers are small compared with the number of surgeries performed each year, officials are frustrated by the fact that wrong-site surgeries occur at all.

"Health care experts are unanimous in their belief that these types of errors should never happen," said Joint Commission President Dennis S. O'Leary, MD. "Unlike many other health care dilemmas, we know how to solve this problem."

Solutions suggested in the Joint Commission alert include:

Marking the surgical site. This can include a physician signing their name or initials or writing "wrong" or "no" on the other side.
Creating and using a checklist that may include medical records, x-rays or imaging studies.
Orally verifying the surgery, with members of the surgical team confirming they have the correct patient and confirming the procedure.
Taking a "time out" to double-check the procedure and patient's identity before starting the operation.
Establishing a monitoring system to ensure procedure compliance.

The Joint Commission worked with the American Medical Association, the American College of Surgeons and the American Academy of Orthopaedic Surgeons to create and disseminate these recommendations.

50 wrong-site surgeries were reported in 2000, 57 in 2001.

Representatives from the four organizations participated in a Dec. 5, 2001, telephone news conference. The conference was widely reported on in the national media.

Because the extensive news coverage brought public attention to the issue, AMA Secretary-Treasurer and Trustee and Joint Commission Commissioner Donald J. Palmisano, MD, said this latest alert might succeed where the other one failed.

"This is a call to patients, before it was a call to professionals," said Dr. Palmisano, a New Orleans-based general and vascular surgeon. "Now we're adding the patient to the mix and approaching it as a team. It's important to put the patient as a partner in this process."

During the press conference, both Dr. Palmisano and Terry Canale, MD, past president of the American Academy of Orthopaedic Surgeons, recommended that the patient not be anesthetized until they see their surgeon.

"When I operate on the patient, I always go in the room to make sure the patient can see me," Dr. Palmisano said. "I do it for two reasons: I want to make sure it's my patient; and second, I want the patient to have the comfort of knowing that I am there before they go to sleep."

Just before surgery is a good time to speak with the patient and mark the surgical area, Dr. Canale said.

"I think it's very appropriate to have the patient ask to see a surgeon and have the patient ask the surgeon to sign the site," said the Germantown, Tenn.-based physician. "We ran into difficulty with some surgeons saying they are too busy, they have too many operations to do that day.

"When they tell that to me, I say, 'Listen, buddy, you are the guy that needs this, you are the guy that's going to get into trouble. ... You are going to make that mistake.' "

Dr. Canale recounted the academy's disappointment when surveys found the sign-your-site program the AAOS initiated met with only a 60% success rate. He calculated that one of out of every four orthopedic surgeons who practice for 25 years will perform at least one wrong-site surgery.

"Operating on the wrong site is completely preventable," he said. "It can be prevented completely by doing the sign-your-site program and, if the surgeon won't do it, the patient ought to demand that he do it."

ADDITIONAL INFORMATION:

The numbers on what went wrong

Of the 150 wrong-site surgeries reported since 1995, the Joint Commission on Accreditation of Healthcare Organizations has root cause analysis information on 126.

Of those cases: 41% relate to orthopedic/podiatric surgery; 20% to general surgery; 14% to neurosurgery; 11% to urologic surgery. Others included dental/oral maxillofacial, cardiovascular-thoracic, ear-nose-throat, and ophthalmologic surgeries.

Fifty-eight percent of these surgeries occurred in either a hospital-based ambulatory surgery unit or a freestanding ambulatory setting, 29% took place in an inpatient operating room, and the remaining 13% happened in inpatient locations such as an emergency department or intensive care unit.

Surgeries on the wrong body part or site accounted for 76% of the total, 13% involved the wrong patient, and 11% involved the wrong procedure.

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Joint Commission alert (http://www.jcaho.org/news_frm.html) , "Simple steps by patients, health care practitioners can prevent surgical mistakes," Dec. 5, 2001