Barriers to Implementing Wrong Site Surgery Guidelines: A Cognitive Work Analysis

Abstract

In this paper, we explore the barriers wrong-site surgery guidelines face when applied in current work practice. Over 40 hours of direct observation of the entire care process (from initial consultation through post-operative care) were conducted. A breakdown in communication between surgical team members and the patient, operating room policy and procedures, incomplete patient assessment, staffing issues, distraction, and availability of pertinent information were identified by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 1998. In response to the high visibility of wrong-sited surgeries, the American Academy of Orthopedic Surgeons (AAOS) among others, developed guidelines intended to reduce the risk but failed to account for the dynamic complex environment. Several process elements emerged from our analysis of observation and interview data as they affected the outpatient surgical process of identification. This paper suggests strategies to enhance resiliency already present in the system.