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?