Reducing the Risks of Wrong Site Surgery Using the Joint Commission’s Targeted Solutions Tool for Safe Surgery

The purpose of this project was to utilize the ‘Institute for HealthCare Improvement’s Model of Improvement as a consultation framework to facilitate improvement in core processes for the prevention of wrong site surgery (WSS) using The Joint Commission Targeted Solutions Tool for Safe Surgery© Program at a surgery center in Mississippi. The TST Program was conducted across 6 months and had 6 phases: 1) Getting Started, 2) Training Data Collectors, 3) Measuring Risk Factors, 4) Analyzing Data, 5) Implementing Solutions, and 6) Sustaining the Gains. A convenience sample of 47 surgical staff participated and 8 data collectors observed behaviors. The nurse consultant, using the TST program assisted staff in reducing the risk of WSS from 16% to 9% in surgical booking, 86% to 53% in pre-op/holding, and 73% to 25% in the OR and empowered them to make 9 practice decisions (just-in-time coaching; improved communication between scheduling and pre-admissions; OR schedule fax back; primary documents within 48 hours before surgery; standardized patient verification; set up regional block time-out (TO) and role-based TO; standardized surgical site marking, and adoption of a surgical checklist). WSS is an avoidable event. Nurse consultants play a powerful role in enabling surgical staff to reexamine existing practice, change behavior, and create a culture of safety in reducing the risks of WSS and promoting patient safety