LEAVING THEIR MARK The optimal site marking is the one that all of your clinicians can agree on and commit to use.

The number of reported incidents of wrong-site surgery has increased since implementation of the Universal Protocol, though experts believe that might be due to better reporting, not necessarily more errors. But because these incidents are being reported, it's obvious this "never event" still occurs. Here are 5 things you need to know about why surgeons continue to operate in the wrong place and what you can do you make sure it doesn't happen on your watch.

1. Human error is to blame
When it comes to wrong-site surgery — and to a larger extent, any patient safety event — health care tends to rely on humans to prevent the problem.

Take the ATM as an example. In older models, users would consistently leave their card behind, since the machine sucked it in for the transaction and only returned it at the end. To fix this, banks made a hardwired technology change that lets users keep their cards throughout the process. In contrast, if designers had relied on stickers or signs reminding you to take your card, there still would be potential for human errors.

Unfortunately, there hasn't been a hardwired technology change like the evolution of the ATM that ensures every operation goes perfectly every time. That means the responsibility lies with your staff and physicians to mitigate any potential risks. There's a risk of wrong-site surgery during every procedure. Make that point perfectly clear to your staff and surgeons.

2. Time outs aren't enough
The Joint Commission's Universal Protocol is one of the most significant advances in the fight against wrong-site surgery. And while it's a good place to start, your prevention efforts should begin well before the day of surgery.

After a wrong-site surgery occurs, researchers look for factors that led to the mistake. They often find they occurred in the days or weeks before the procedure instead of in the OR. Consistently we find that the time out couldn't have stopped the error — instead, it started way upstream. An incorrect consent, a mismarked pre-op document or even the patient mistakenly identifying the operation can lead to wrong-site surgery.

PAUSE POINT Time outs are effective if staff and surgeons are active participants.

Because of that, your staff and surgeons must look for opportunities to prevent wrong-site surgery throughout the entire surgical process, not just in the OR. Every time patient information is passed along in your facility — including from the surgeon's office to the scheduler, to pre-op and to the OR — it should be checked against the "gold standard," typically the original documents from the surgeon's office. By being proactive, you can limit mistakes in the OR caused by oversights that occur upstream.

3. Standardization is essential
You cannot have a policy that simply requires surgeons to mark the surgical site, without some additional structure and details. Ambiguity is one of the main reasons clinicians do not follow guidelines. This type of policy creates the possibility of marking variation — one surgeon might write "yes" on the surgical site, another may write "no" on the opposite appendage — that leads to errors.

Instead, the optimal site marking for any surgery is the one that all of your clinicians can agree on and commit to use. Having a single way for every single physician to mark the site is best, but at the very least each type of surgery should have a consistent marking policy.

Once a decision on how all sites will be marked is made, make it clear that all physicians are expected to follow the policy. If a particular specialty feels it has a better method for their procedures, allow those clinicians to present their argument to leadership. If their fellow clinicians back them up, consider allowing the deviation. The key here is that any allowed variation of site marking occurs by surgery type, not by individual surgeons.

4. You must prove the site is right
Even though the time out has been adopted by most healthcare organizations, wrong-site surgery is still happening. While, as discussed above, many errors start upstream, the time out is still an essential part of your prevention efforts.

What researchers have found is that too often these checks that are designed to prevent errors are being done mindlessly. Instead of attentively going through checklists, staff and surgeon go through the motions and look at it as just one more step in the process.

One explanation for this is that healthcare professionals have a tendency to be optimistic. We expect the surgery to go smoothly, with no errors or harm to the patient. There's a "preoccupation with failure" in other safe organizations or industries. In aviation, for example, pilots are constantly looking for what could go wrong and working to prevent it before it happens, which increases overall safety.

Stress to staff and physicians that instead of assuming things are always right for every case, they should assume things will go wrong and make an effort to prove things are correct. For example, the discussion during a time out shouldn't be "We're operating on the left knee." Instead, the surgical team should say, "We're operating on the left knee because the original documentation shows us that, and the patient herself agreed in pre-op."

5. Changing the culture isn't impossible
Researchers who studied incidents of wrong-site surgery cases found that 90% of the time someone felt like something was wrong during the case, but didn't speak up. Usually it's because they were afraid of being embarrassed. Or worse, staff did speak up, but were ultimately ignored. Harming a patient is a high price to pay for poor teamwork and communication.

Everyone in the OR must be encouraged to speak up if they see something wrong. Your surgeons are the ones who inspire this culture in the OR. Typically, though, that's easier said than done. The key thing to remember is that surgeons are drawn to logic and reasoning.

When I talk to doctors about enhancing teamwork, I discuss the science behind why teams make good decisions. While a surgeon may think that years of training or education is the foundation of wise decisions, research has discovered 2 distinct attributes that enhance a team's overall decision-making.

The first is that they welcome and embrace diverse and independent input. In your facility, that translates to nurses, techs or even schedulers sharing information freely as a team. Whenever someone speaks up about something that doesn't look right, the physician should celebrate the sharing of information, even if he believes the information is wrong. Remind surgeons that by welcoming more input from everyone, the team as a whole becomes safer.

The second is that wise decision-making teams build in pause points. Stress to surgeons the importance of using the time out as a pause point that's beneficial to both the team and the patient. For example, instead of the robotic answer of, "We're operating on the left breast," the surgical team should take a moment to think "Are we sure this is correct?"

It takes time, but surgeons are driven by data and evidence. By showing your physicians that adopting these 2 attributes will help them get the best outcomes possible for patients, they'll be much more likely to lead the charge.