Wrong Site Surgery Tool


On February 14, a new tool was introduced to help fight wrong site surgery incidents. Developed by the Joint Commission Center for Transforming Healthcare, the Targeted Solution Tool (TST) will take healthcare officials through a step-by-step process to identify, measure, and reduce the risk of accidental surgeries.

According to the Joint Commission Center for Transforming Healthcare, the national incidence rate is as high as 40 per week. That includes wrong site, wrong procedure, wrong side surgeries, and wrong patient mistakes.

The TST ultimately helps organizations elevate risks with their surgical systems. The new tool helps with scheduling, pre-operative, and operating room areas when risks are high, and looks for weaknesses that may cause wrong site surgeries.

In 2009, eight U.S. hospitals and ambulatory surgical centers came together to form the wrong site surgery project in hopes to address the problems and find solutions. The organizations that participated used Robust Process Improvement (RPI) methods, which is a fact-based and data-driven problem-solving methodology. These methods were able to discover the causes of preventable breakdowns in patient care and stop them.

The participants involved in the project soon discovered 29 main causes of wrong site surgeries. The TST was then pilot tested by six hospitals and ambulatory surgical centers.

During the project, the original eight organizations were able to reduce the number of surgical errors by 46 percent in the scheduling area, 51 percent in the operating room, and 63 percent in pre-op, according to the Joint Commission.

Date: April 6, 2014

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