Despite years of patient-safety efforts, an increasing number of healthcare facilities have reported mistakenly removing the wrong limbs or organs, slicing into the wrong side of bodies and performing surgery on the wrong patients. The Joint Commission, in its September 7, 2007 publication of the Sentinel Event Statistics, indicates that wrong site surgery remains the highest reported event.  Last year, healthcare facilities reported 94 operations to the commission that involved the wrong body part or the wrong patient. While some states, including New Jersey, require hospitals to report such slip-ups, many hospitals across the nation are not obligated to account for them publicly. Since the introduction of the Joint Commission’s Sentinel Event Policy, the Joint Commission has reviewed numerous cases related to surgery and have identified several factors that may contribute to the increased risk of wrong site surgery.  These risk factors include:

·         more than one surgeon involved in the case, either because more than one surgery is contemplated or the care of the patient required more than one surgeon

·         unusual time pressures, related to an unusual start time because of emergent situations or pressure to speed up the pre-operative procedure

·         incorrect site preparation by the staff and incorrect interpretation of X-rays

·         unusual patient characteristics such as physical deformity or morbid obesity that might alter the usual process for equipment set-up or positioning of the patient

The root causes identified most often are related to the following major themes:

·         incomplete or inaccurate communication among members of the surgical team

·         inadequate pre-operative assessment of the patient and the procedure or lack of procedure to verify the correct surgical site

·         the failure to engage the patient or family member in the procedure of identifying the correct surgery 

The following graph published by the Joint Commission shows further breakdown.