Furthering the preventive cause, Dr. Anthony Ardire, Senior Vice President of Quality and Patient Safety at Lehigh Valley Health System, spoke about what his organization has done to reduce and eliminate wrong-site surgeries.

Dr. Ardire listed several steps that contributed to the Lehigh Valley Health System's success in reducing and eliminating wrong-site surgeries. One crucial step is the commitment from the organization's leadership to patient safety.

"At Lehigh Valley we have full support from senior administrative and clinical leadership on patient safety issues, in particular, wrong-site surgery prevention," Ardire said. "Wrong-site surgery events are thoroughly evaluated with a formal root-cause analysis and are reported regularly to our organization's Performance Committee and Board of Directors."

Other important steps include collaborations that involve strategically placed posters as visual reminders and special stickers that promote time outs prior to surgery.

A time out is the last in a series of steps launched in July 2004 as part of the Joint Commission's Universal Protocol for Preventing Wrong-Site, Wrong Procedure and Wrong Person Surgery. The step requires that a "time out" occur to verify correct patient, correct procedure and correct site before any surgery begins.

"It surprised many that since the Joint Commission launched its Universal Protocol, there has been a sustained increase, not decrease, in the number of reported cases of wrong-site surgeries," added Ardire. "While some of the rise may be due to increased reporting, the fact remains that the incidence and frequency of this problem is not decreasing."

Ardire said since the implementation 18 months ago of Lehigh Valley Hospital's wrong-site surgery and procedure protocols, they have eliminated all wrong-site surgery and wrong-site procedures.

"It does take diligence on everyone?s part to prevent wrong-site surgeries and procedures," Ardire said. "We believe you can?t rely solely on education. Visual reminders, tracking and investigation of all events and near misses and multi-disciplinary collaboration are required."

Michael Doering, interim executive director of the Patient Safety Authority, spoke about the Authority?s plans to reduce and eliminate wrong-site surgeries in Pennsylvania.

"This summer, the Authority will begin to visit and interview several volunteer facilities on their wrong-site surgery protocols," Doering said. "Once we gather this comprehensive information, we will have a better understanding of what works and what doesn't in preventing wrong-site surgeries. Based upon this information we will provide guidance to facilities that we believe will help prevent wrong-site surgeries."

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