A Culture of Safety Stops Wrong-Site Surgeries Cold

Workplace Culture Patient Safety

By: Carlos Pellegrini, MD, FACS

Published: 10/20/2022

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Following safety protocols to the letter during every case can prevent these events from happening.


A high-volume OR is booked to perform six consecutive hand surgeries. Five are scheduled on the right hand, and one, the fourth operation of the day, which is scheduled for 3 p.m., is scheduled on the left hand. This patient is late, so the last patient of the day, whose operation is planned for the right hand, is wheeled in earlier. In addition, there is a nurse change at 3 p.m. and the surgeon, after being in the operating room and seeing the patient, is called to the ER for a quick consult. The team, believing it is the 3 p.m. patient, preps the left hand, and everything is ready when the surgeon comes into the OR ... and the incision is made in the wrong hand.

Who’s at fault? And how can we prevent this from happening?

There are a myriad of examples of how events such as wrong-site, wrong-patient or wrong-procedure surgeries continue to happen in facilities that have supposedly airtight policies in place to confirm the patient’s identity, procedure type and  location of the surgery they’re about to undergo. The good news is wrong-site errors are virtually 100% avoidable if protocols and necessary redundancies are followed in a meaningful fashion — and if facilities don’t spread themselves too thin or cut corners to skirt protocols exactly as they are written. Events like the one described above, don’t occur with the same frequency in facilities that have strong safety cultures and adequate communication among their OR team. Here are the keys to making these wrong-site surgeries true never events.

• Meaningful timeouts. It all starts with the timeout, a great opportunity for the entire team (nurses, physician assistants, technicians, anesthesia and surgeons) to “team up,” introduce the patient, discuss the operation and invite everyone’s participation. There are plenty of resources full of well-established procedures and processes that can help you reduce wrong-site events, including The Joint Commission’s Universal Protocol, The Joint Commission Center for Transforming Healthcare’s Safe Surgery Targeted Solutions Tool and the World Health Organization’s Surgical Safety Checklist. A discussion with patients before the operation about the specifics of the procedure they’re about to undergo, a timeout in which the patient’s history and the kind of operation that’s going to take place is discussed and the clear marking of the surgical site are all cornerstones of safe surgical practice and a reflection of a culture of safety. If the timeout is done correctly and the surgical checklist is used with focus, it’s almost impossible to do a wrong-site surgery or perform a wrong procedure. Nothing is impossible, but these safeguards make it a lot less likely for these events to occur. However, if you fail to do it, or if you just go through the motions and treat the timeout like a routine thing while you’re thinking of something else, then it’s worthless. In fact, when performed in this manner, it is potentially harmful, providing the team with a false sense of security. Listen to the patient and your team members, and always be engaged. You simply can’t be thinking of something else when you ask the patient their name and what procedure is about to be performed on them and in the case of bilaterality, which side.

• Customized processes. The Joint Commission’s Targeted Solutions Tool (TST) offered for free to all facilities accredited by the JCO is a personalized way to look at their processes, to identify threats and analyze errors that are peculiar to the institution, so as to define ways in which those threats can be minimized. If you’re using an electronic health record to schedule a procedure that only requires clicking a box that says “right” or “left” to note the side of an operation, you may want to build in follow-up questions confirming the correct side was registered. This built-in redundancy is crucial and mirrors a procedure in other high-reliability organizations like the airline industry. For example, when instructions are issued by air traffic control to pilots, especially at crucial times like landing, the crew repeats those instructions to air-traffic controllers, a process known as a “copy response.” The facility-specific nature of the TST can help you create a true culture of safety, because you’re conducting a threat analysis that addresses the threats identified for your institution. This process looks at all details of perioperative operations and allows you to assess all the threats in your institution through a lens that’s geared toward maximizing their prevention.

How Often Do Wrong-Site Events Actually Happen?
NATIONAL INVENTORY NEEDED

Nineteen “wrong surgery” events were reported to The Joint Commission (JCO) from Jan. 1 to June 30, according to statistics released by the commission last month. The truth, however, is we don’t truly know the magnitude of the problem.

Ninety percent of the sentinel events reported to JCO in this timeframe were self-reported by facilities, and the other 10% were reported by patients, their families or employees of the facilities. The murky picture of the extent of wrong-side, wrong-patient, wrong-anesthetic and wrong-patient surgeries needs to be made clearer so we can determine whether our attempts to prevent them have been successful.

That requires some uniformity. Currently, state health department rules on reporting wrong-site events vary widely, with Pennsylvania having the most stringent requirements. It would be extremely helpful for all states to mandate reporting these events, so we’d have a national inventory that would produce numbers we can rely on — something we don’t have now. Not only would this inventory allow us to know the actual number of incidents that took place, but it would also alert us to whether these events were increasing or decreasing. For instance, we believe that surgical timeouts have made a difference, but we don’t really know. And if we can’t measure this accurately, we don’t know if timeouts and other interventions have given us the results we expected — and whether additional changes would be appropriate.

 — Carlos Pellegrini, MD, FACS

HARD STOP All members of OR teams must feel comfortable speaking up if they suspect an error is about to take place.

• Acknowledge shortcomings. In medicine, we’re less likely to follow protocols with the same regularity – or borderline obsession — that other high-reliability industries do. There are a lot of seemingly valid excuses and a lot of, “but this is what I’ve always done.” We need to take a page from industries like aviation, nuclear plant operators and amusement parks, and make sure the standard operating procedures we institute are carried out all the time. Be more compulsive and resist the temptation become relaxed and complacent about safety threats that rarely ever occur.

• Flatten the hierarchies. Check that surgical teams are running ORs in a way in which all comments are welcome. Team leaders must assure that all members of the OR team feel that their participation in the operation is key to the success of the procedure. It’s not enough to assume that everyone is free to speak. In a true culture of safety, every team member owns part of the operation, and feels that his or her participation is vital. This is when flattening hierarchies becomes an art, not just a statement. A common way I used to induce medical students to participate more actively in an operation was to tell them that while observing and helping they have to feel that they fully understand and agree with what the surgeon is doing. If there is something they do not understand, they have the obligation to say so because that means one of only two things can be happening: Either the student does not have enough knowledge about that part of the procedure, in which case this gives the surgeon the opportunity to teach, or the surgeon is distracted and actually making a mistake and the question at that time prompts the surgeon to correct the error. Questions from team members should always be encouraged. It keeps the team focus on what they are doing. One should always be careful on how to handle questions, particularly if an answer cannot be provided at a crucial time of the operation. 

• Eliminate distractions. There should be as much emphasis on not talking about what you’re not doing as there is on talking about the case at hand. Regularly remind staff to avoid any extraneous conversations about the movie they saw last week, facility gossip or who’s leaving or starting a new job there. Putting pre-op images up on video monitors for the entire team also helps. In addition to orienting everyone to what will be done, and on what part of the body it will be performed, it’s also an opportunity to humanize the patient and briefly discuss their medical history, what you’ll be doing to solve their current problem and what issues might be particular to them. This simple act also increases the likelihood of a team member saying, “No, it’s not supposed to be the right knee, it’s the left.”

• Communicate clearly. Surgeons should always communicate when they’re going to divert from their normal operations. When I was performing a lot of stomach procedures, I would usually do a total plication, but sometimes I would do a partial plication. If I don’t communicate that subtle change, team members could feel intimidated and not speak up if they thought I was going to do it a different way. They assume I know what I’m doing, and 95% of the time, they’re right. But the patient needs staff to speak up for the five percent of the time I might be distracted — or even wrong.

By minimizing the threats of human errors, you’ll significantly decrease the number of mistakes you’re capable of making. None of us are immune to these threats, so we need to rely on the abundant safeguards at our disposal with intention. OSM

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