Surgical Safety: Addressing the JCAHO Goals for Reducing Wrong-site, Wrong-patient, Wrong-procedure Events

Sandra Ludwick


Under standards set forth by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), health care facilities are required to implement established patient safety goals. The efforts by a team at the Naval Hospital, Cherry Point, NC (NHCP), to address and prevent wrong-site surgery have resulted in an initiative that can easily be implemented within other facilities. After developing a surgical verification checklist, the NHCP wrong-site surgery initiative adopted consistent, facilitywide policies that required staff to ensure that all surgical procedures are done on the right patient and at the right location, and that the correct procedure is performed. A mechanism to measure the effectiveness of the new initiative by recording and tracking data was put into place. Within the first 4 months of implementation, the operating room (OR) had reached its benchmarking goal of 100 percent compliance with surgical verifications. In addition, a simple educational tool displayed in numerous OR and clinic areas serves as a reminder to caregivers and consumers that patient safety is at the top of the NHCP priority list.

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