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Jt Comm J Qual Saf. 2004 Jul;30(7):405-10.

Righting wrong site surgery.

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Center for Quality and Productivity Improvement, University of Wisconsin-Madison, USA.



As defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), wrong site surgery includes wrong side or siteof the body, wrong procedure, and wrong-patient surgeries. Although many health care organizations are implementing guidelines and procedures to decrease the occurrence of wrong site surgery, numerous barriers to their effectiveness have been identified.


A human factors system analysis can be used to better understand how elements of a work system combine andinteract to contribute to breakdowns in the system. A case study of wrong site surgery in an outpatient setting illustrates how the different work systtem elements can contribute to the occurrence of a wrong site surgery. In analyzing the care process, it is particularly important to identify the transitions of care, which can be sources of patient safety problems when deficits in communication and information transfer occur (for example, miscommunication, information not transmitted on time, wrong information transmitted, misunderstanding of the information transmitted).


After a wrong site surgery, conduct a root cause analysis that uses the work system model and includes a surgery care process analysis similar to the one described in the case study; collaborate with human factors engineers to learn how to apply the work system model; apply the work system model to process analysis; and optimize work systems.

[Indexed for MEDLINE]

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