Development Background at a Glance
According to the best available estimate, there are approximately 40-60 wrong site surgeries per week in the United States.* Research has shown that, often, there is usually no one root cause of failure. Rather, such events are frequently the result of a cascade of small errors that are able to penetrate organizational defenses. As a result, the Center joined forces with the Lifespan system in Rhode Island to initiate the Safe Surgery project in July 2009. The goal was to improve the safeguards to prevent wrong site, wrong side and wrong patient surgical procedures by helping organizations identify, measure, and reduce risks across their surgical process areas, including scheduling, pre-operative, and operating room areas.
Because the occurrence of wrong site surgery is rare, with most organizations going years without an occurrence, the TST was designed to monitor surgical cases for weaknesses that could result in wrong site surgery, thus speeding up the ability to correct issues with the surgical process without the need to wait for a wrong site surgery to actually occur. In 2010, four additional hospitals and three ambulatory surgical centers joined the project. The original participating organizations were able to reduce the number of cases with risks by 46 percent in the scheduling area, 63 percent in the pre-op area, and 51 percent in the operating room area.
The organizations that participated in the Center’s project identified 29 main causes of wrong site surgeries that occurred during scheduling, in pre-op or pre-op holding, in the operating room, or which stemmed from the organizational culture.
*Chassin MR, Loeb JM: High-reliability health care: Getting there from here. The Milbank Quarterly, September 2013;91(3):459-490, (accessed November 10, 2013)