Why Does Wrong-Site Surgery Keep Happening?

Wrong-site surgery is devastating for the patient, the staff who worked the case and the surgeon who made the incorrect cut. Still, the avoidable error remains the third most reported sentinel event related to perioperative services, according to Deborah Spratt, MPA, BSN, RN, CNOR, NEA-BC, CHL, an independent perioperative consultant based in Rochester, N.Y. Ms. Spratt is incredulous that wrong-site surgery still occurs, despite implementation of global checklists, safety protocols and education initiatives aimed at preventing it. “In 2006, the New York State Department of Health developed a protocol addressing and identifying wrong-site surgery as a top priority,” she says. “It’s 2022, and we’re still having the same conversations. You’d think we would have solved the problem by now.”

There are a few key things that can prevent this never event from occurring — once and for all.

• 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.”

There are many factors that contribute to wrong-site surgery, and even the current staff shortage can play a role, especially in positions that are crucial to maintaining clear communication with the surgical team. “The job market is tenuous, so instead of having an OR scheduler who has been in the role for 10 or 20 years, inexperienced staff members are handling the responsibilities,” she says. “They might not have the same institutional knowledge of how to ensure correct information from surgeons’ offices reaches the OR. That can lead to errors.” 

Increased pressure during surgery caused by having to perform surgery faster or start cases on time, or even interpersonal issues, can negatively impact the collaboration that’s crucial to preventing never events. “I’ve been in the OR since 1973,” says Ms. Spratt. “The culture has definitely improved, but team dynamics among surgical, nursing and anesthesia professionals can contribute to wrong-site surgery.”

When you create a culture of safety for patients and staff, look at the whole process. “Establish a consistent and standardized system for preventing wrong-site surgery that everyone believes in,” says Ms. Spratt. “It can be difficult to get buy-in until there’s an incident, but by then it’s too late.” OSM