3 Preop Safety Errors Risking Wrong Site Surgery (And How to Empower Improvement)


Use Time Out 2023 on June 14 to pause and improve commonly reported risks that impact safety, suggests Haytham Kaafarani, MD, MPH, FACS, Joint Commission Chief Patient Safety Officer and Medical Director.

“As a surgeon myself who has been part of busy OR teams, I have seen how one can slip into the trap of treating the Time Out as mundane,” cautions Joint Commission Chief Patient Safety Officer and Medical Director Haytham Kaafarani, MD, MPH, FACS.

But Time Out provides the very last safety check before incision for the team to communicate and catch any information that has been dropped or noted incorrectly, he stresses. “Just one error at any time in the preoperative process can and does cascade to patient harm.”

Take Time for Time Out

With National Time Out Day approaching on June 14, we asked Kaafarani what teams can do to reinvigorate attention to this long-standing patient safety check to prevent significant errors such as wrong site surgery.

His answer: Take a collective pause. Address any deficiencies in how you conduct Time Out, site marking and other elements of the Universal Protocol. “Despite decades focused on improving safety and quality with tools such as Time Out, wrong site surgery is still occurring at a predictable rate – we have to ask why this is happening.”

3 Team Approaches to Reduce Wrong Site Surgery

Root Cause Analysis data from wrong surgery sentinel events reported to The Joint Commission suggest common team errors, including:

  • Lack of full team attention during Time Out
  • Inaccurate and non-visible site marking
  • Not instilling a “speak up” culture, especially among new team members

To combat these errors and reinvigorate preoperative safety practices, Kaafarani suggests three key actions.

  1. Empower One Team Member to Enforce Full Team Attention for Time Out

“Time out must always be recognized as a primary step, not an action secondary to other OR activities,” Kaafarani recommends. Too often, team members are allowed to simultaneously proceed with other activities during the Time Out (such as continuing to drape or check the instruments and equipment) and this lack of full attention means those team members “are not fully tuned to communicate patient information or raise a concern.”

He suggests enlisting one person responsible for rallying the team to fully engage in the Time Out. That means “giving this individual the authority to remind any team member not giving full attention during the Time Out that they need to do so, even during a routine surgery, during any surgery.”

  1. Refine Site Marking to Be More Accurate and Visible

Investigations show that surgeries in areas such as fingers, toes, or spine — where there are several of the same body parts — are the highest risk for wrong site surgery, and this is for three major reasons, Kaafarani explains:

  • Site marking is not being done in a specific and meaningful way. For example, a site marking for surgery on the 4th finger may be placed at the wrist to protect the surgical site; however, this opens the door for a wrong finger to be operated on. Instead, “mark the actual surgical site at the finger, or, if not feasible, mark the wrist but add an arrow to the 4th finger to ensure the team all agrees visually and verbally which finger is being operated on.”
  • Site marking for surgery to non-visible organs is not possible. For example, surgery to the L4 of the spine cannot be marked. So, “good practice is to have the radiographic imaging in the OR and review this imaging as a team to double and triple check surgical site accuracy prior to incision and during the procedure.”
  • Site marking is out of view. The site marking should not be intentionally or accidentally placed under the drape at the point of the Time Out. “Every member of the team should confirm site marking is done, visible, and appropriate—the Time Out should be an opportunity to recheck correct surgical site marking as a team.”
  1. Require a Culture Where Everyone Feel Safe to Speak Up

Although safety culture improvements have come a long way, team members still need to be encouraged to speak up, even if their concern is wrong, Kaafarani stresses. For example, consider a team member whose first four times speaking up were not validated…they will be far less likely to speak up that 5th time when a concern could be founded. “The challenge is to applaud someone for speaking up when they are wrong, because this will encourage them to always speak up.”

Given widespread staffing shortages — which Kaafarani attributes as the number one danger facing healthcare in general, including the OR, today — it’s especially critical to instill confidence in new team members to speak up to prevent patient harm.

The Benefits of Planning Every Time to Avoid Wrong Surgery

Kaafarani’s final suggestion is for teams to focus on all the ways wrong surgery can occur. “Think for every case: this is the case when a wrong surgery will occur, so what safety steps can I take to prevent it? Keep this mentality for every procedure and treat each case with each step done perfectly.”  

For anyone who thinks wrong site surgery is so rare that it doesn’t warrant this level of attention, Kaafarani asks them to consider the cost of no action – to the patient of course, who is the one put in preventable harm’s way, but also for the surgical team members as second victims. “The dangers of the second victim phenomena are completely underappreciated, surgeons leave the profession or change practices over errors such as wrong surgery, and the impact and repercussions of this are huge for the future of safe surgery.”

Resources to Explore as a Team

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