In 2004, the Joint Commission mandated a "universal protocol" to prevent wrong site surgeries. This three step process includes pre-surgery patient identification, marking the correct surgical site and surgical "time out" immediately before the surgery commenced. In 2011, there is a lack of consistency in how these three checks are being performed among organizations being studied. Lack of consistency allows for continued mistakes or near misses. The number of wrong procedures reported to one Colorado medical liability carrier rose between 2002-2008. The Wrong Site Surgery Project has helped to identify simple mistakes with large potential to cause harm including not using indelible ink to mark the surgical site, marking the site too far away or the mark not being visible once the surgical drapes were applied. Related links:
Wrong Site Surgery Project, Joint Commission Center for Transforming Healthcare (www.centerfortransforminghealthcare.org/projects/display.aspx?projectid=4)
"Reducing the Risk of Wrong Site Surgery," Joint Commission Center for Transforming Healthcare (www.centerfortransforminghealthcare.org/UserFiles/file/ CTH_WSS_Storyboard_final_2011.pdf)
"Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era," Archives of Surgery, October 2010 (archsurg.ama-assn.org/cgi/content/abstract/145/10/978)