JCAHO sentinel event alert: wrong site surgery preventable - Joint Commission on Accreditation of Healthcare Organizations - Brief Article

AORN Journal, Jan, 2002

According to a sentinel event alert issued Dec 5, 2001, by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), performing a procedure on the wrong site or the wrong patient or performing the wrong procedure on a patient is completely preventable and should never happen. In a sentinel event alert to approximately 18,000 health care facilities nationwide, JCAHO called on the health care community to take specific safety steps and enlist the help of patients to eliminate these tragic mistakes, according to a news release from the organization.

To help avoid surgical errors, JCAHO encourages patients to have their surgical site marked with a permanent marker. The organization also recommends that health care staff members take the following steps.

* Physicians should initial the surgical site using a permanent marker in a way that cannot be overlooked and then actually perform the procedure through or next to the initials.

* Immediately before the procedure begins, all surgical team members should confirm orally that they have the correct patient, correct surgical site, and correct procedure.

* Team members should take a "time out" in the OR to perform a last double-check of the patient's charts and corroborate information with the patient.

During its on-site quality evaluations, JCAHO representatives will ask accredited health care facility staff members how they are protecting patients from wrong site surgeries, according to the release.

AORN's Position Statement on Correct Site Surgery is available on AORN Online at http:// www.aorn.org/about/positions/correctsite.htm. The document also is available in the June 2001 issue of the AORN Journal, pages 1066 to 1067. For more information about the sentinel event alert issued by JCAHO, visit SSM Online at http://www.ssmonline.com.

Joint Commission Issues Alert: Simple Steps by Patients, Health Care Practitioners Can Prevent Surgical Mistakes (news release: Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations, Dec 5, 2001) 1-2 http://www.jcaho.org/news/WSS_ PressKit/news release.html (accessed 6 Dec 2001).