The Partnership for Patient Care announced the first initiative of 2008 as an improvement collaborative focused on Wrong Site Surgery. With the goal of eliminating the occurrence of wrong site surgery in our region, ECRI Institute facilitated a comprehensive program that included education, technical assistance, tools, and an interactive forum to help hospitals in implementing safeguards and interventions to prevent wrong site surgery. The program faculty was led by John Clarke, M.D., Clinical Director for Patient Safety and Quality Initiatives at ECRI Institute, a trauma surgeon acknowledged as the nation’s leading authority on wrong-site surgery.
Over 90 participants representing 31 organizational teams attended the first collaborative workshop on March 12, 2008 at the ECRI Institute. Dr. Clarke identified the key elements of prevention: assuring accurate documentation and patient consent; independent verification of the surgical site at each hand-off;, appropriate site marking; and an effective “time out” prior to incision. The workshop included the analysis of actual case studies reported to the Pennsylvania Patient Safety Authority. The participating teams prepared a baseline assessment of their practices and completed observations for a sample of 10 cases in the operating room. Three topic-focused conference calls were held in April, with the concluding workshop on May 7, 2008, to address implementation challenges, lessons learned, and preliminary program results. The program was rated “good” to “excellent” by 100% of the participants. The participating teams will complete a follow-up assessment of their practices and gather post-program observational data from the operating room.