5 Steps to Reduce Wrong-patient/Wrong-site Surgery

Accreditation Monthly, September 6, 2005

Dear Colleague,

"The Week in Healthcare" column appearing in the August 22, 2005 issue of Modern Healthcare cited a rather remarkable and tragic statistic regarding the ongoing incidence of wrong-patient or wrong-site surgery in the State of Florida. Between August 2004 and July 2005 the State Board of Medicine reported adjudicating 41 reported cases of wrong-patient or wrong-site surgery including nine cases occurring as recently as April 2005.

This disturbing result has occurred in spite of the JCAHO National Patient Safety Goals dating back to January of 2003 that address and require hospitals to adopt preventative measures to avoid wrong-patient, wrong-procedure, or wrong site surgery. These measures were redrafted in July 2004 and codified in the JCAHO's "Universal Protocol." Additionally, in February of 2004 the State of Florida Board of Medicine instituted a "pause rule" that mirrors the JCAHO "time-out" process.

One wonders what the true number of reported and unreported episodes of wrong-patient or wrong site surgery is nationally. Given what we know about applying principles of effective process design in healthcare, our industry should be capable of totally eliminating the incidence of this type of medical error. How is it then that we continue to have even one single reported case of wrong-patient, wrong-site surgery in this country? Why do we tolerate even a single failure or single data point representing undesired variation in practice?

Very simply, I believe the answer rests in our failure as leaders to attend to one or more of what I call the Five Steps of Doing The Right Thing Well.

  1. We may not have designed the process properly. For example, perhaps we created a workable process for use in the surgery department but failed to account for how the process also needs to be applied in all other areas where invasive procedures are performed.

  2. Maybe we did fine job designing a fool-proof process (recognizing as once said by a wise person - that there is no process design outside the capability of a sufficiently talented fool!), but we failed to adequately educate the users of the process.

  3. We may have a great process and we had great attendance and attention at our department inservices, but perhaps we failed to follow-up and test for staff competency - that is - are staff capable (competent) to consistently apply on the front line what they've learned in the classroom.

  4. Even though our process, education, and competency validation steps may be stellar, maybe we can trace process failure to management's lax or insufficient measurement of staff conformance to following precisely the steps in the process we designed and taught. Perhaps staff left the classroom educated and competent but instantly reverted to old habits that to them seemed as much or even more efficient and effective than we designed.

  5. Finally, maybe processes fail because we failed as leaders to have the backbone, time or energy to hold staff accountable to ensure they perform the process as we designed without variation.

I hasten to add that when I refer to "staff" in each of these Five Steps I am including physicians as applicable. After all, the source of the undesired variation in practice may well be a disinterested, or worse, disruptive physician who's passive or active resistance to change dampens or even swamps efforts to instill a culture of safety among all staff in a department.

Applying the Five Steps to any process design or redesign project increases your organization's odds of Sustaining Variation-Free Execution of your new process. I suggest all hospitals use this report from Florida as an opportunity to gather staff from all areas where invasive procedures are performed and conduct a careful review of your applicable policy and checklist(s) or form(s). Compare these tools to the JCAHO "Universal Protocol" and Frequently Asked Questions found at

Ask yourselves if you've captured each nuance of the "Universal Protocol" and FAQ in your process design. Did you teach the process design to all applicable staff and validate their competency? Have you adequately measured staff conformance to the process design? And if not, have you intervened to ensure staff is held accountable to perform the process as designed? If you answer yes to each Step you are on the path to Sustained Execution of the "Universal Protocol" process.


John Rosing
Practice Director of Accreditation
and Regulatory Compliance
The Greeley Company

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