Schedule breakdowns and poor time outs open the door for wrong-site surgeries to sneak past surgical teams as often as 40 times per week. That's the finding of 8 hospitals and surgical centers that investigated the causes of wrong-site procedures as part of the Joint Commission Center for Transforming Healthcare. The leaders at some of the participating facilities share what they found.

Scheduling snafus
Scheduling problems often arise as a result of a simple lack of communication, says Martha Rush, BSN, RN, CNOR, surgery nurse manager at AnMed Health Women's and Children's Hospital in Anderson, S.C. While the facility hasn't had a wrong-site event since opening in 1998, the hospital did find some communication gaps in the scheduling department that needed filling, says Ms. Rush. Schedulers struggled with capturing accurate information when surgeons' offices called to schedule procedures. Or illegible handwriting on a faxed scheduling form caused uncertainty over a procedure's specifics. The solution to this problem was right under their noses. Implementing the unused scheduling module in its existing electronic medical record system has helped the hospital reduce the number of daily scheduling errors from about 15 to less than 1.

The project team also found that AnMed Health surgeons' staffs weren't always clear on what sort of information they needed to provide patients before surgery. In response, the team created a manual for each surgeon's office, which outlines all information needed to schedule cases, and explains which patients are eligible for phone assessments instead of in-person assessments.

Half-hearted time outs
The Joint Commission project also cited time outs being done without the full participation of all key individuals as another contributor to wrong-site events. Thomas Jefferson University Hospital used its involvement in the Joint Commission project as a chance to review the effectiveness of its pre-op checklist and time-out process, says Richard Webster, RN, vice president for perioperative services at the Philadelphia, Pa.-based academic medical center.

In the past, the OR nurse leading the time out did all the speaking, he says. Surgeons and other key members of the OR team weren't required to participate, other than a nod to acknowledge confirmation of the procedure and site. To make the time out "more interactive and role-based," TJU has added steps to involve the entire team, says Mr. Webster. Working from a pre-op checklist that Mr. Webster describes as "our own version of the WHO surgical safety checklist," the surgical team introduces itself individually to the patient, and confirms any allergies or special requirements the patient may have. (Visit www.who.int/patientsafety/safesurgery/ss_checklist/en to download the WHO checklist.) The physician also identifies himself to the patient and confirms the type of procedure being performed. The rest of the team — anesthetist, nurses, technologists — individually verbalize their agreement, and the surgeon is asked directly if he has any concerns about the pending procedure. The nurse still leads the time out, but requiring each team member to respond with "more than a nod of the head" is a way to get them more engaged, says Mr. Webster.

AnMed Health refined its time-out process as well, says Ms. Rush. In pre-op holding, the anesthetist identifies the patient, verifies the site and side, and marks the patient, says Ms. Rush. During the actual time out, the surgical team references the site mark, which underscores the importance of making sure the mark is visible after the patient is prepped and draped, adds Ms. Rush. The patient and procedure are verified with the surgeon using the consent form, and the team also reviews pre-op images taken of the patient, either on the picture archiving and communication system or in hard copy form.

These moments before the first incision offer one last chance for definitive confirmation, says Mary Cooper, MD, JD, senior vice president and chief quality officer at Providence, R.I.-based Lifespan Corporation. Lifespan, which owns a 5-hospital system in Rhode Island, helped initiate the wrong-site surgery project. Having experienced 3 wrong-site incidents in 2 years at its flagship Rhode Island Hospital, the time seemed right to reconsider many of its processes, including the pre-op time out.

When the surgeon is ready to make the initial incision, the room essentially comes to a halt, says Dr. Cooper. When the surgeon puts his finger on the marked site, everyone must stop what they're doing and the room must be quiet, she explains. With his finger on the site, the surgeon asks everyone if they can see the mark. Each person in the room must provide verbal confirmation, says Dr. Cooper. For example, if a circulating nurse is at a computer in a corner of the room, she has to come over and give her verbal confirmation. "If we can't do that, we can't continue," says Dr. Cooper. "It's doing these "little things' that prevent the process from being carried forward incorrectly."

Are the right systems in place?
Raising awareness and educating your team are just part of solving the wrong-site puzzle, says Dr. Cooper. Wrong-site procedures "aren't about individuals in the OR who are careless or malevolent," she says. "It's about systems that fail our teams. We always rely on our people to be superheroes that jump in and make sure nothing bad happens to the patient," says Dr. Cooper. "But we first have to make sure the right processes are in place."