• Consistent messaging. One of the ways to prevent wrong-site surgery is continuing staff education, according to Ms. Spratt, who recommends routine training for the entire perioperative team on at least a yearly basis. “In-services
should include residents, surgeons, anesthesia providers, nurses, surgical techs, schedulers — really everyone who’s involved in patient care,” she says.
Regular staff education should focus on ensuring correct sites are communicated from surgeons’ offices to the OR, standardized site-marking protocols are used and surgical sites are confirmed during safety time outs. Also review wrong-site
surgery events or near misses with a culture focused on open discussion and transparency, suggests Ms. Spratt.
When an event or near miss occurs, determine what went wrong and when. Identifying when the error occurred is especially important because there are many touchpoints during which something can go wrong between the time a patient is scheduled
for surgery and when the correct site is being confirmed in pre-op and the OR. “Surgery is a team sport,” says Ms. Spratt. “Everyone is equally accountable for the issues that occur.”
• Effective time outs. Having a consistent time out process in place is crucial to preventing wrong-site surgery, notes Ms. Spratt. The time out process should be standardized across your facility and include a visual system such
as a poster-sized checklist hung on the OR wall. The Universal Protocol, developed in 2004 by the Joint Commission, includes requirements for marking the surgical site in pre-op using prep-resistant ink, confirming the patient’s
identity and intended procedure, and having the surgical team review those details prior to the start of surgery.
• Adjunct technology. A new technology aims to prevent wrong-site surgery through digital verification of the correct procedure. The platform includes a mobile software application, a forcing function and data reporting tool to
improve communication among surgical teams, surgeons’ offices, surgical facilities and patients. Surgeons can use the platform to record their discussions with patients in the clinic about the planned procedure, including the site
and laterality. This cloud-based statement of the intended surgical plan and verbal confirmation by the patient is accessible leading up to the procedure, including just before the time out, to help providers confirm the correct patient
and site. The platform also has a visual cue component, which uses alliteration and colors to help staff identify the correct site of the surgery: Lavender procedure cards that travel with the patient identify procedures taking place on
the left side of the body, while rose cards identify surgeries taking place on the right side of the body.
We’re still having the same conversations. You’d think we would have solved the problem by now.
— Deborah Spratt
A member of the pre-op team uses the platform’s app to listen to the recording of the surgeon-patient statement and scans the proper procedure card into the system. In the OR, members of the surgical team also listen to the statement
before conducting the safety time out, which is recorded by the app.
In a study involving use of this technology, researchers found no incidences of wrong-site surgery in 487 orthopedic procedures. However, the tool did catch 17 near misses. The researchers were surprised by how many seemingly small errors
occurred, including misspelled names and laterality mistakes, and that they were caught at various points of care between surgeons’ offices and operating rooms. The technology can track these close calls and advance staff education
and communication by reporting them objectively to surgical leadership.
• Smart scheduling. Ms. Spratt notes there are multiple factors that contribute to wrong-site surgery. She recalls that during her time as a surgical director, a very experienced surgeon and surgical team had been performing knee
arthroscopies all day. During one of the cases, it was discovered the surgeon had performed a wrong-side surgery. “The case involved a seasoned surgeon, circulator and scrub tech,” says Ms. Spratt. “It was everyone you’d
want taking care of you, and wrong-site surgery still happened.”
After performing the correct procedure on the other knee, the entire team took a close look at the root causes of the event and made a relatively simple change in practice to prevent it from occurring again. “They decided to schedule
left knees on one day and right knees on another, so equipment didn’t need to be switched and there was no confusion about laterality,” says Ms. Spratt.
• Empowered staff. If any member of the surgical team feels something isn’t right about where the surgeon intends to operate, they should feel comfortable speaking up and stopping the procedure before a devastating result
occurs, notes Ms. Spratt. In the study of the wrong-site surgery prevention technology mentioned above, a close call involved a patient who was scheduled to undergo a left knee replacement, but a pre-op nurse noticed the surgical schedule
and the case’s source document noted the patient’s right knee had to be replaced. The patient had already received a sedative, causing the surgeon to cancel the case because the patient couldn’t participate in confirming
the correct site or consent to the correct procedure being performed. “It’s awesome the surgeon made that decision,” says Ms. Spratt. “That was the right thing to do.”