Statement from The Joint Commission on Surgery Protocol Project with Rhode Island Hospital and Newport Hospital

November 4, 2009

Even though wrong site surgery should never happen, by The Joint Commission’s estimates, wrong site, wrong side and wrong patient procedures occur more than 40 times every week in the United States.

Since July 2009, The Joint Commission’s Center for Transforming Healthcare has been working with Rhode Island Hospital and Newport Hospital, which volunteered for this national demonstration project, to improve the safeguards to prevent patients from undergoing wrong site, wrong side and wrong patient surgical procedures. This project is addressing the problem of wrong site surgery using Robust Process Improvement™ (RPI), a systematic and data-driven, problem-solving methodology. RPI incorporates specific tools and methods from Lean Six Sigma and change management methodologies. The project team includes hospital leadership, surgeons, operating room staff and physicians from Rhode Island Hospital and a team from the Center that is expert in RPI.

The Joint Commission Center for Transforming Healthcare recently developed and recommended solutions that are designed to reduce the risk of wrong site surgery at Rhode Island Hospital. The solutions include:

• Check and verify documents at the time of scheduling a procedure.
• Surgeon to mark the correct surgical site in the pre-operative area.
• Point to the surgical site during the Time Out.
• Streamline paperwork to further decrease distractions.
• Define the roles and responsibilities of team members for conducting pre-operative marking, identification and Time Out.
• Empower everyone on the team to stop the process if there are any concerns.

These solutions are focused on caregivers being in the right roles and performing the right tasks. The solutions also build on The Joint Commission’s Universal Protocol. Rhode Island Hospital will be testing these solutions over the next few months.

Find out more about the Surgery Protocol Project 

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