According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards, all accredited health care facilities are required to implement established patient safety goals. Recent efforts made to address and prevent wrong-site surgery by a team at Naval Hospital, Cherry Point, NC (NHCP), have exemplified the wrong-site prevention goal, as well as its intent. Those efforts have manifested in the development of a wrong-site prevention initiative that can easily be communicated and implemented within other health care systems, thereby assisting in creating a culture of safety and increasing facility patient safety efforts.

Organizational culture change is never easy. It begins with the establishment of common goals and an understanding that such goals reflect “buy-in” or a vested interest by the participating group members. Trying to get any group to come to a common agreement on anything can be, and often is, quite exhausting. However, JCAHO, through its accreditation standards, serves as one of the best examples of a catalyst for cultural change. In essence, JCAHO establishes standard practices to assure safe patient care and recognizes health care organizations that adopt the standards with a certificate of accreditation.

organization adopts the common goals of JCAHO, it must also buy into the JCAHO philosophies behind the standards, i.e., to understand or adopt the intent of the standard as well as implementing the standard itself. Here begins NHCP’s journey toward cultural change in the operating room (OR) area regarding the patient safety goal of preventing wrong-site surgery.

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