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Is Your Wrong-site Surgery Protocol Foolproof?
Anthony Ardire
Publish Date: October 27, 2008   |  Tags:   Patient Safety

Preventing surgery on the wrong body part or patient is the aim of the Joint Commission's universal protocols. So why do these so-called "never events" still happen? Because the surgical timeout is sometimes seen as a speed bump on the road to surgical efficiency and not an integral part of the facility's culture of safety and communication.

The emphasis on high volume in the ambulatory setting puts no more or no less emphasis on pre-op surgical site and patient identification checks as compared to inpatient surgery. Staff and surgeons alike in both settings must make those precautions as routine as donning gloves. Preventing wrong-site or wrong-patient surgeries actually begins before the patient reaches the OR. Follow these steps for each patient that walks through the door on the day of surgery.

  • Pre-procedure verification. What procedure will the surgeon perform and where? Review it with the patient at registration. Confirm it in the patient's chart and on the consent form.
  • Procedure site marking. The surgeon must identify and mark the procedure site. Some initial it, while others write "yes" where the incision should be made. The key is to set a uniform standard within your facility and stick to it to avoid confusion. Keep in mind that an "X" is unacceptable. Adhesive labels may be affixed to the skin, but only in addition to the proper markings.
  • The timeout. The entire surgical team - that includes nurses, techs, anesthesia providers and the surgeon - must gather around the patient, preferably before anesthesia is administered and certainly before the incision is made. The group should verify the patient's name, the procedure and incision site or sites with a check of the surgeon's markings. The group should also ensure that the patient is positioned properly and the required equipment - including implants, if need be - is on hand.

Watch these lapses
Those are the basics emphasized during every orientation program and annual training session. You'd think surgical misidentifications would be a thing of the past, yet regardless of how often you emphasize the importance of surgical timeouts, mistakes happen. Have your staff watch for the following wrong-site surgery risk factors.

  • Multiple incision sites or multiple docs. Don't relax after the shoulder is closed and the knee still needs to be fixed. When one surgeon hands over the patient to another doc, make sure confirmation of the second incision site's location is also passed along. Multiple surgeries performed by multiple surgeons increase the risk factors.
  • Time pressures. It doesn't take much more than a delay of a few minutes for the surgical team to feel the time crunch. Running behind schedule leads to shortcuts being taken. That's when mistakes happen. Think about the patient's well-being before your facility's daily case throughput.
  • Incomplete pre-op assessment. Skipping or rushing checks in the pre-op area just puts more pressure on the OR staff to catch a potential mistake.
  • Hidden markings. Markings may be covered by socks, a blanket or drape, depending on the position of the patient.

Confronting the surgeon
At my hospital, circulating nurses complete a form to document that the surgical team completed all steps of a proper timeout. We also affix timeout stickers to instrument trays and hang timeout posters to serve as constant visual reminders of our hospital's safety policies. Each employee is implored to take ownership in the hospital's safety record. Nurses are empowered by the hospital's administration to stop a surgery if the proper precautions aren't followed.

It can be difficult for nurses or techs to confront a surgeon. While most surgeons are onboard with a facility's safety efforts, difficult personalities are a reality of life in the OR. Try this hard-and-fast rule: A challenge from any two members of the surgical team necessitates an automatic and immediate consult for a consensus on what's being done and by whom.

Expanding on the timeout
Not only does the timeout provide an opportunity to identify inconsistencies and to prevent errors in the OR, but by improving overall communication it helps empower all members of the team to continue the dialogue during the operation if things do not seem to be going according to plan. In fact, we're not only focused on ensuring the surgical timeout, but we're also looking to expand on it. In 2008, in addition to preventing wrong-site surgeries, we're aiming to have timeouts confirm that the patient received the proper antibiotic 60 minutes before surgery.

The Joint Commission requires that doctors "sign their site." Yet a study in the September 2006 issue of the journal Archives of Surgery reports that the problem may be 20 times more common than previously thought, occurring between 1,300 and 2,700 times a year and that prevention efforts may be inadequate.

Inside Pennsylvania's Wrong-site Surgery Data

Wrong-site surgical errors occur in Pennsylvania's healthcare facilities every other day, according to an advisory from the state's Patient Safety Authority. The report claims that the authority received 174 reports of actual wrong-site surgery events and 253 notifications of near-misses between June 2004 and Dec. 2006.

"Wrong-site surgeries in Pennsylvania should never occur," says Stan Smullens, MD, chief medical officer at Jefferson Health System in Radnor and vice-president of the Patient Safety Authority's board of directors. "However, we are not alone. Wrong-site surgeries are no more common in Pennsylvania than they are in other states. We also have in common with other states the problem of trying to fix them."

Of the 174 reported cases of wrong-site events, 69 percent were wrong-side surgeries, 14 percent occurred on the wrong body part, nine percent were wrong procedures and eight percent involved the wrong patient.

Orthopedic and ophthalmic procedures were the most common for wrong-site surgeries. Common risk factors for the reported incidences of wrong-site surgery include multiple procedures performed on the same patient, possibly by multiple surgeons; staff communication breakdowns; time pressures; incomplete pre-op assessments and cultural factors that may deter staff from questioning the surgeon's authority.

- Daniel Cook