AORN Position Statement

Statement on Correct Site Surgery

PREAMBLE
Wrong site surgery can and must be prevented.¹ Wrong site surgery is a broad term that encompasses all surgical procedures performed on the wrong patient, wrong body part, wrong side of the body, or at the wrong level of the correctly identified anatomic site.² The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) considers all wrong site surgeries, regardless of the extent of the procedure or the outcome, to be reviewable sentinel events.

A comprehensive approach is needed in each health care delivery system to prevent wrong site surgery. Procedures and protocols should be developed collaboratively by multidisciplinary teams, including perioperative registered nurses, surgeons, anesthesia care providers, risk managers, and other health care professionals to implement the "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery."¹ As patient advocates, perioperative registered nurses should communicate with all members of the surgical team to verify the correct surgical site. Individual facility policy should clearly delineate the role and responsibility of the physician and other team members in marking and verifying the correct surgical site. Perioperative registered nurses should be key participants in multidisciplinary teams as they develop these procedures and protocols. As patient advocates, perioperative registered nurses have a duty to the public to protect the patient from injury and to safeguard the patient's health, welfare, and safety.³ Although it is the surgeon's responsibility to diagnose a patient's need for surgery and to delineate the surgical site, verifying the correct surgical site at the time of surgery is the responsibility of perioperative registered nurses and every member of the health care team.

POSITION STATEMENT
AORN is dedicated to patient safety. Using suggested risk-prevention strategies for identification and verification of correct patient, surgical site, and procedure will reduce the risk of error. AORN endorses JCAHO's "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery"¹ (Exhibit A) and "Implementation Expectations for the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery"⁴ (Exhibit B).

Editor's note: "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery" is a trademark of the Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, Ill.

References
1. "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery," Joint Commission on Accreditation of Healthcare Organizations, http://www.jointcommission.org/NR/rdonlyres/E3C600EB-043B-4E86-B04E-CA4A89AD5433/0/universal_protocol.pdf (accessed 4 Nov 2008).
2. Joint Commission on Accreditation of Healthcare Organizations, "Sentinel events," in Comprehensive Accreditation Manual for Hospitals (Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations, 2004) SE-3.
3. "AORN explications for perioperative nursing" in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2004) 53-83.
4. "Implementation Expectations for the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery," Joint Commission on Accreditation of Healthcare Organizations, http://www.jointcommission.org/NR/rdonlyres/4CF3955D-CD1F-4230-86C5-D04485CAFBEA/0/IG_final.pdf (accessed 4 Nov 2008).

Original statement adopted by the AORN Board of Directors in November 2004; ratified by the House of Delegates, New Orleans, in April 2005.
Sunset review: March 2010

EXHIBIT A: UNIVERSAL PROTOCOL FOR PREVENTING WRONG SITE, WRONG PROCEDURE, WRONG PERSON SURGERY™
Wrong site, wrong procedure, wrong person surgery can be prevented. This Universal Protocol is intended to achieve that goal. It is based on the consensus of experts from the relevant clinical specialties and professional disciplines and is endorsed by more than 40 professional medical associations and organizations.

In developing this protocol, consensus was reached on the following principles:

Wrong site, wrong procedure, wrong person surgery can and must be prevented.
A robust approach-using multiple, complementary strategies-is necessary to achieve the goal of eliminating wrong site, wrong procedure, wrong person surgery.
Active involvement and effective communication among all members of the surgical team is important for success.
To the extent possible, the patient (or legally designated representative) should be involved in the process.
Consistent implementation of a standardized approach using a universal, consensus-based protocol will be most effective.
The protocol should be flexible enough to allow for implementation with appropriate adaptation when required to meet specific patient needs.
A requirement for site marking should focus on cases involving right/left distinction, multiple structures (fingers, toes), or levels (spine).
The Universal Protocol should be applicable or adaptable to all operative and other invasive procedures that expose patients to harm, including procedures done in settings other than the operating room.

In concert with these principles, the following steps, taken together, comprise the Universal Protocol for eliminating wrong site, wrong procedure, wrong person surgery:

Preoperative verification process

Purpose: To ensure that all of the relevant documents and studies are available prior to the start of the procedure and that they have been reviewed and are consistent with each other and with the patient's expectations and with the team's understanding of the intended patient, procedure, site, and, as applicable, any implants. Missing information or discrepancies must be addressed before starting the procedure.
Process: An ongoing process of information gathering and verification, beginning with the determination to do the procedure, continuing through all settings and interventions involved in the preoperative preparation of the patient, up to and including the "time out" just before the start of the procedure.

Marking the operative site

Purpose: To identify unambiguously the intended site of incision or insertion.
Process: For procedures involving right/left distinction, multiple structures (such as fingers and toes), or multiple levels (as in spinal procedures), the intended site must be marked such that the mark will be visible after the patient has been prepped and draped.

"Time out" immediately before starting the procedure

Purpose: To conduct a final verification of the correct patient, procedure, site and, as applicable, implants.*
Process: Active communication among all members of the surgical/procedure team, consistently initiated by a designated member of the team, conducted in a "fail-safe" mode, ie, the procedure is not started until any questions or concerns are resolved.

© Joint Commission on Accreditation of Healthcare Organizations, 2003. Reprinted with permission.

EXHIBIT B: IMPLEMENTATION EXPECTATIONS FOR THE UNIVERSAL PROTOCOL FOR PREVENTING WRONG SITE, WRONG PROCEDURE, AND WRONG PERSON SURGERY™
These guidelines provide detailed implementation requirements, exemptions, and adaptations for special situations.

Preoperative verification process

Verification of the correct person, procedure, and site should occur (as applicable):

At the time the surgery/procedure is scheduled.
At the time of admission or entry into the facility.
Anytime the responsibility for care of the patient is transferred to another caregiver.
With the patient involved, awake, and aware, if possible.
Before the patient leaves the preoperative area or enters the procedure/surgical room.

A preoperative verification checklist may be helpful to ensure availability and review of the following, prior to the start of the procedure:

Relevant documentation (eg, history and physical, consent).
Relevant images, properly labeled and displayed.
Any required implants and special equipment.

Marking the operative site

Make the mark at or near the incision site. Do NOT mark any nonoperative site(s) unless necessary for some other aspect of care.
The mark must be unambiguous (eg, use initials or "YES" or a line representing the proposed incision; consider that "X" may be ambiguous).
The mark must be positioned to be visible after the patient is prepped and draped.
The mark must be made using a marker that is sufficiently permanent to remain visible after completion of the skin prep. Adhesive site markers should not be used as the sole means of marking the site.
The method of marking and type of mark should be consistent throughout the organization.
At a minimum, mark all cases involving laterality, multiple structures (fingers, toes, lesions), or multiple levels (spine). Note: In addition to preoperative skin marking of the general spinal region, special intraoperative radiographic techniques are used for marking the exact vertebral level.
The person performing the procedure should do the site marking.
Marking must take place with the patient involved, awake, and aware, if possible.
Final verification of the site mark must take place during the "time out."
A defined procedure must be in place for patients who refuse site marking.

Exemptions

Single organ cases (eg, Cesarean section, cardiac surgery).
Interventional cases for which the catheter/instrument insertion site is not predetermined (eg, cardiac catheterization).
Teeth-but, indicate operative tooth name(s) on documentation or mark the operative tooth (teeth) on the dental radiographs or dental diagram.
Premature infants, for whom the mark may cause a permanent tattoo.

"Time out" immediately before starting the procedure
Must be conducted in the location where the procedure will be done, just before starting the procedure. It must involve the entire operative team, use active communication, be briefly documented, such as in a checklist (the organization should determine the type and amount of documentation) and must, at the least, include:

Correct patient identity.
Correct side and site.
Agreement on the procedure to be done.
Correct patient position.*
Availability of correct implants and any special equipment or special requirements.

The organization should have processes and systems in place for reconciling differences in staff responses during the "time out."

Procedures for non-OR settings including bedside procedures

Site marking must be done for any procedure that involves laterality, multiple structures, or levels (even if the procedure takes place outside of an OR).
Verification, site marking, and "time out" procedures should be as consistent as possible throughout the organization, including the OR and other locations where invasive procedures are done.
Exception: Cases in which the individual doing the procedure is in continuous attendance with the patient from the time of decision to do the procedure and consent from the patient through to the conduct of the procedure may be exempted from the site marking requirement. The requirement for a "time out" final verification still applies.

*AORN has requested that JCAHO add "patient position" to the purpose statement of the "'Time out' immediately before starting the procedure." Richard Croteau, MD, executive director for strategic initiatives at JCAHO, is bringing that request forward. In the meantime, Dr Croteau clarified that "the presence of this language in the implementation guidelines for the Universal Protocol following the statement 'must, at the least, include' makes this a firm requirement of the protocol. That is, the guidelines are part of the protocol, and wherever the word 'must' is used, what follows is held by the Joint Commission to be a requirement for purposes of accreditation." In other words, the correct patient position must be verified during the time out immediately before the start of the procedure.