Joint Commission announces new case study on wrong-site surgery safety

Editor’s Note

The Joint Commission on December 5 announced a new, free educational tool that details wrong-site surgery safety strategies–identifying risk factors and possible ways to improve processes.

The case study lays out a situation in which a patient is scheduled for transbronchial biopsies of the right upper lung but has biopsies of the left lung instead.

The tool asks readers:

• What are the risk points?
• How could the error have been prevented?
• How could the error have been mitigated?
• How can the system be improved?