Preventing Incorrect Procedures

Incorrect procedures can be such things as the wrong procedure being performed or a procedure being performed on the wrong body part or even on the wrong patient! These incorrect procedures can happen in the operating room environment but many occur outside of the operating room. For example, other locations where these incorrect procedures are common include radiology, labor and delivery, and minor procedure suites.

The Joint Commission identified a number of factors contributing to the increased risk for wrong site, wrong person, or wrong procedure surgery. These included emergency cases, unusual physical characteristics (e.g. morbid obesity or physical deformity) unusual time pressures to start or complete the surgery, unusual equipment set up in the operating room, multiple surgeons involved in the case, and multiple procedures being performed during a single surgical visit. Another study (Neily et al., 2009) found that adverse events were more common in ophthalmic and orthopedic surgeries inside the operating room and outside of the operating room, they were reported most often for invasive radiology procedures.

The root causes identified by hospitals cited in the Joint Commission study usually involved multiple factors, but the main one was a breakdown in communication between caregivers and the patient and family. Other factors included not having policies in place or not complying with the policy (for example, to mark a surgical site clearly), not doing a thorough assessment, and not completing a surgical checklist. The study by Neily also found that communication breakdown was the top root cause at 21.0% and included examples such as informed consent issues and problematic communication between team members. 17.6% of root causes in their study related to time-out problems (the period of time to assess, plan, communicate, and complete checklists per policy) included issues such as the patient not being properly identified during the time-out.