IEEE TRANSACTIONS ON SYSTEMS, MAN, AND CYBERNETICS—PART A:SYSTEMS AND HUMANS, VOL. 34, NO. 6, NOVEMBER 2004 757 Barriers to Implementing Wrong Site Surgery Guidelines: A Cognitive Work Analysis Michelle L. Rogers, Richard I. Cook, Robert Bower, Mark Molloy, and Marta L. Render Abstract—In 1998, the Joint Commission on Accreditation of Healthcare Organizations identified important contributors to surgical site misidentification in the operating room (OR), including communication breakdown between surgical team members and the patient, availability of pertinent information, failure of OR policies and procedures, incomplete patient assess- ment, and distraction. Prior to this, the American Academy of Orthopedic Surgeons (AAOS) among others, developed guidelines intended to reduce the likelihood of misidentification in surgical procedures. We hypothesized these guidelines were inconsistently implemented because of the failure to account for the dynamic complex OR environment. Over 40 h of direct observation of the entire care process (from initial consultation through post- operative care) were conducted at two hospitals. Our analysis identified critical process elements that impact the outpatient surgical process of identification. Time pressure, crosschecking, uncooperative communication culture, complexity in the work process, attention/distraction, and documentation concerns make guidelines that rely on verification of the site complicated and vulnerable to error. Suggestions for improvements in processes are made. Index Terms—Collaborative work, human factors, medical deci- sion-making, surgery. I. INTRODUCTION I N 1998, the Joint Commission on Accreditation of Health- care Organizations (JCAHO) reported that the numbers of wrong-site surgeries were on the rise despite several high-pro- file cases and the national attention being paid to medical er- rors [1]. In that year, close to 20 wrong-site surgeries were re- ported. By December 2002, more than 60 wrong-site surgeries had been reported. In a review of their root cause analyses re- ports, JCAHO identified six common factors that contributed to wrong-site surgeries: 1) emergency cases; 2) unusual patient characteristics; 3) intense time pressure; 4) operating room (OR) characteristics; 5) involvement of multiple surgeons, or 6) mul- tiple procedures during a single OR visit, with the majority of Manuscript received March 31, 2004; revised June 4, 2004 and July 27, 2004. This paper was recommended by the guest editors of this special issue. M. L. Rogers and M. L. Render are with the Getting at Patient Safety (GAPS) Center, Department of Veteran Affairs, Cincinnati, OH 45220 USA and the Division of Pulmonary and Critical Care, College of Medicine, University of Cincinnati, Cincinnati, OH 45221 USA (e-mail: michelle.rogers@med.va.gov; marta.render@med.va.gov). R. I. Cook is with the Cognitive Technologies Laboratory, University of Chicago, Chicago, IL 60637 USA (e-mail: ri-cook@uchicago.edu). R. Bower and M. Molloy are with the Department of Veteran Af- fairs, Cincinnati Medical Center, Cincinnati, OH 45220 USA (e-mail: Robert.Bower@med.va.gov; Mark.Molloy@med.va.gov). Digital Object Identifier 10.1109/TSMCA.2004.836805 cases involving a breakdown in communication [2]. In this in- terval, wrong-site surgeries also increased in the percent of er- rors reported, from approximately 8% of all errors in 1998 to more than 15% of the total in 2002 [2]. In light of these find- ings, a national alert was issued to rally the medical community. JCAHO reviewed its root cause analyses reports and identified contributors to adverse events resulting in wrong-site surgery. The top seven contributors were: 1) communication, 2) orienta- tion/training; 3) patient assessment; 4) availability of informa- tion; 5) procedural compliance; 6) OR hierarchy among team members; and 7) distraction. Several agencies [3]–[5] including the American Association of Orthopedic Surgeons (AAOS), the American College of Sur- geons, the Joint Commission on Accreditation of Healthcare Or- ganizations (JCAHO), Association of OR Nurses (AORN), Vet- erans Health Administration (VA), and the VA National Center for Patient Safety proposed “best practices” guidelines to pre- vent misidentification during surgery following the lead of their Canadian counterparts [6]. Among these guidelines, only the VA tested and iteratively refined their guidelines at ten hospitals be- fore mandating a guideline to ensure correct surgery [5]. All of the published guidelines include one or more of the following: 1) marking the surgical site; 2) involving the patient in the marking of the site; 3) using a verification checklist; 4) verifying the site by obtaining oral verification from the patient and/or family member and from each member of the surgical team in the OR; 5) monitoring compliance with these procedures; 6) incorporating “time outs” to assure the correct patient, procedure and site using active rather than passive com- munication. Despite “best practice” recommendations, a survey by the AAOS following their marketing campaign in the 1990s to “mark the site” found that only 40% of orthopedic surgeons initial or mark their operative sites [7]. In fact, little empiric evidence addresses the efficacy, the cost or the unexpected consequences in implementing these new “best practices” in the OR [8]. Examining how the “best practice” recommenda- tions interact with workflow processes closes a critical gap in the knowledge base regarding effective interventions to reduce the risk of wrong-site surgery. To examine the interaction, we used a human factors engineering approach of observation and interviews to characterize care processes, artifacts (or tools), and team interactions that promoted (facilitators) or hindered (barriers) correct identification in successful surgical procedures [9]–[11]. 1083-4427/04$20.00 © 2004 IEEE