Musings...Ambulatory Patient Safety
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Michael Kulczycki, Ambulatory Health Care
The musings of a healthcare executive – concerned about patient safety in ambulatory settings – who writes about the industry…..accreditation & safety issues, customer trends, stakeholder news, and developments at The Joint Commission, the nation’s largest accrediting body.
Reducing the risk of Wrong Site Surgery
Jul 12, 2011 | 740 Views
The Joint Commission Center for Transforming Healthcare recently released the results of a Targeted Solutions Tool project on reducing the risk of wrong site surgery. 3 ambulatory surgical centers and 5 hospitals worked with The Center to find out why wrong-site, wrong-side, and wrong-patient procedures occur more than 40 times every week. The ASC industry, via Ambulatory Surgery Foundation, provided access to the ASC community as part of this Center project.
Twenty-nine main causes were identified as preventable breakdowns in medical care for wrong-site surgeries. Some of the factors identified that were found to contribute to wrong-site surgery were scheduling, ineffective communication, lack of verbal site verification, and lack of participation in time-out activities.
Results of the project found that errors or defects could be reduced if quality and measurement are reinforced, a culture of safety is emphasized, knowledge of wrong-site surgery is strengthened, and surgical process consistency is improved. As part of the project, participating organizations were able to reduce the number of defective cases involving surgical booking from a baseline of 39% to 21%, in pre-op from 52% to 19%, and in the OR from 59% to 29%. The incidence of cases containing more than 1 defect decreased 72%. Cases containing one or more defects were decreased by 57% in surgical booking, decreased by 75% in pre-op, and decreased by 76% in the OR. A single operative case has multiple opportunities for defects, which is why it was so important to focus on eliminating defects. Multiple defects in a single case can further increase the risk of an error reaching a patient. When more than one procedure was performed, it was found that the incidence of defective cases increased.
For further information on the reducing the risk of wrong site surgery project, please visit the Center’s website. There you will find a storyboard and video describing the project. A link to the targeted solutions for this project will be available on the website in late 2011.
In addition to this project, the Center is working on projects using the Targeted Solutions Tool on the topic of hand-off communications, and reducing surgical site infections. Results of these additional projects will be published in late 2011 or early 2012.
The Targeted Solutions Tool is available to all Joint Commission accredited organizations via the secure Joint Commission extranet. This is a value-added component exclusively for accredited Joint Commission customers. For individual ambulatory providers, it gives you all the tools to help address your ambulatory-specific issues. Let’s work together to improve patient care in our ambulatory settings!
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