Three years after it first sounded an alarm about wrong-site surgery, the Joint Commission on Accreditation of Healthcare Organizations has issued a follow-up alert in the wake of 136 new cases since 1998.
Nearly 60% of the cases, most of them voluntarily reported to the JCAHO, occurred in hospital-based or freestanding ambulatory surgery settings. About 30% of the mistakes were made in an inpatient operating room.
The original alert was among the first dispatches on sentinel-event trends involving serious medical mistakes. The wrong-site reprise earlier this month was the 20th such alert.
"The know-how to create systems that prevent wrong-site surgery has existed for years, yet the number of errors has not decreased," said JCAHO President Dennis O'Leary, M.D. The commission collected 16 incidents in 1998 when the first alert was issued. The number of reported cases rose to 28 in 1999, 50 in 2000 and 58 so far in 2001, including 11 in November.
Part of the reason for the increase is a change in culture about admitting medical errors, said JCAHO spokeswoman Charlene Hill. Nine wrong-site incidents were reported from 1995 to 1997, the first years of the commission's push to record sentinel events. "Each year there's been a marked increase in the number of hospitals reporting," Hill said. "The comfort level of reporting is there."
The most likely mistake involved surgery on the wrong body part, which constituted 76% of the incidents. Surgery on the wrong patient accounted for 13%, and the wrong surgical procedure was done in 11% of the cases. Orthopedic surgery, at 41%, was the most common procedure involving wrong-site surgery.
The JCAHO's latest sentinel-event alert recommended that healthcare facility staff mark the surgical site with a permanent marker, orally verify the surgery just before starting the operation and go through a pre-operative checklist to corroborate information from medical records and diagnostic images.