The Big Three Wrong-Site Specialties


A new study especially worth reading this month, with June’s National Time Out Day, examines the root causes of wrong-site surgeries in orthopedic, neurosurgery and urology procedures, the three surgical service lines that carry the highest risks for this type of sentinel event.

The February 2023 study,featured in The Joint Commission Journal on Quality and Patient Safety, reviewed claims data of 68 closed cases that took place between 2013 and 2020.

More than a third of the incidents were orthopedic procedures, followed by neurosugeries, which made up 22 percent of wrong-site events. Urology procedures were third, at nearly nine percent. Spine and other disc surgeries comprised the most common procedures involved, followed by arthroscopy and muscle-tendon procedures.

“The top contributing factors to wrong-site surgery were failure to follow policy/protocol (83.8%) and failure to review the medical records (41.2%), the mean closed claim value was $136,452 and 60.3% of cases were settled,” say the study’s authors. “The risk of wrong-site surgeries is increased with spine surgeries, likely due to unique technical challenges.”

The study noted that wrong-site events continue to occur 20 years after The Joint Commission’s 2003 implementation of its Universal Protocol, designed to reduce seminal events via thoughtful time outs, surgical site marking and pre-procedure verification processes. National Time Out Day is a perfect time to reinvigorate facilities’ practices, according to a joint statement by TJC and the Association of periOperative Registered Nurses.

In the statement, the Joint Commission’s Chief Patient Safety Officer and Medical Director Haytham Kaafarani, MD, MPH, FACS, makes three suggestions for HOPDs and ASCs:

  • Mark the site as close and clear as possible to the actual surgical site
  • Use radiographic imaging when site marking isn’t possible for nonvisible organs
  • Keep the site marking visible during all key steps of procedures, including the Time Outs and when the incisions are made

“While wrong site surgery is rare, one occurrence is one too many,” says Dr. Kaafarani. “Together, surgeons, anesthesiologists, nurses, surgical technologists and other members of the surgical team must work together to prevent this type of adverse event. We need to approach every surgical case as if it could be the wrong site surgery one and make every effort from pre-op to post-op to prevent such an adverse event from occurring.”

AORN CEO/Executive Director Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, adds, “As the patient advocate in the OR, perioperative nurses must be passionate champions for an effective Time Out and assure that each member of the team understands the protocol and takes this critical safety check seriously &mdash for every patient before every surgical procedure.”

A useful roundup of time out resources is available at OSM

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