The Joint Commission continues to receive reports of wrong procedure, wrong
patient, wrong site, and wrong side
operations. Although reporting
these events is not mandatory in
most states, some estimates put the
national incidence rate as high as
40 per week.* Wrong site surgery
can have devastating consequences
for patients and health care
providers, and it can be extremely
costly to health care organizations.
To help organizations reduce
the occurrence of this type of
event, The Joint Commission
Center for Transforming
Healthcare launched its Targeted
Solutions Tool (TST) for Wrong
Site Surgery in 2012. This
online tool, highlighted in the
October 2012 issue of the Bulletin
(page 60), guides accredited
organizations through a free,
step-by-step process to identify,
measure, and reduce risks in key
processes that may contribute
to wrong site surgery.† Over the
last three years, the TST has
undergone several improvements
that have led to better results.
*Chassin MR, Loeb JM. High-reliability
health care: Getting there from here. Milbank
Q. 2013; 91( 3):459-490. Available at: www.
Loeb_0913_final.pdf. Accessed May 1, 2015.
†A look at The Joint Commission: ASCs
begin using wrong site surgery tool. Bull
Am Coll Surg. 2012;97( 10): 60. Available at:
surgery-tool. Accessed May 29, 2015.
A LOOK AT THE JOINT COMMISSION
TST: The right operation, on the
right patient, in the right location