Expert Q&A: Wrong-Site Surgery


Why years of time outs and surgical site marking haven't eradicated this never event.

Despite years of preaching and teaching about taking time outs and marking the site, wrong-site surgery is the problem that won't go away. We spoke to John R. Clarke, MD, FACS, a professor of surgery at Drexel University in Philadelphia and clinical director emeritus of the Pennsylvania Patient Safety Authority, to find out why wrong-site surgery is still happening and what you can do to prevent it.

Q Why does wrong-site surgery persist?
When the Patient Safety Authority looks at reported incidents, the problems generally fall into 2 areas — misidentification and misperception. Misidentification is where the wrong body part or person is operated on, either because staff or surgeons are looking at the wrong x-ray, bad information is written in the documents or the patient is confused. It's true that the person most likely to correct wrong information is the patient, but that doesn't mean the patient is always right. Sometimes they're confused, or it could be an issue of a bilateral disease.

Misperception is when the surgeon or staff mixes up the left and right, or the front and back, of the patient despite having the correct information. Twenty percent of the population has right and left confusion, meaning that they can't immediately tell their right from their left without having to think about it first. That means if I say, "Raise your right hand" to a group of people, 20% might raise their left or have to take a few moments to think about it.

Q Has the Universal Protocol helped?
Many people just go through the motions when it comes to the Universal Protocol. Generally, nurses are trying to do the right thing. The physicians are not always as enthusiastic. That's because the reality is that if you ignored the Universal Protocol and never bothered with it, 3 out of 4 doctors, aside from spinal surgeons, would never experience wrong-site surgery. The problem is that a facility doing 10,000 operations a year wouldn't have that same luck. But, for the doctors, the chances are so low they don't give credence to it.

It isn't so much that the Universal Protocol isn't being followed. It's that the Universal Protocol never specifies how things should be done. It gives facilities a checklist of things to do — mark the site, perform a time out — but doesn't really specify the exact ways to do those things. It turns out that when you look closely, as we have and Minnesota has, there are ways of doing things that are going to make errors less likely than other ways.

Q Can you give some examples?
For one, make sure that the very specific site of operation is listed on all documents. It needs to be very detailed and listed on the OR schedule, the consent form and the H&P. Facilities often have the site documented somewhere, but it's often not specific enough or not carried throughout all of the forms.

Another example is marking the surgical site. We see surgeons mark a site just for the sake of marking a site. We even have reports where a surgeon marked the eye when the patient was supposed to have abdominal surgery!

Q What is the right way to mark a site?
First, the doctor should not only use the patient as a reference, but also make sure that the information the patient is giving lines up with the consent, schedule, H&P and the surgeon's memory. As for whether to write "yes" or the surgeon's initials, when the Authority studied this we found that there were fewer wrong-site procedures in the places that use their initials. We don't have an explanation as to why, but I can theorize it's because when the surgeon is required to use his initials, you know it's the surgeon marking it, whereas anybody on the staff can write "yes." It's also important the marked site is visible when the patient is prepped and draped. There's a lot of emphasis on making the mark, and very little emphasis on actually using the mark. If you get in the OR and you're prepping the leg for surgery, that mark should be visible. That way if you don't see it, you know you're probably prepping the wrong leg. Finally, during the time out, that mark should be specifically pointed out. Think of it as the way the patient is participating in the time out. That mark on the left knee is saying "here, here, here!"

time out TIME OUT Make sure staff is actively involved during time outs to lessen your chances of wrong-site surgery.

Q What other mistakes do facilities make in time outs?
During time outs, usually the circulator recites information, everyone agrees, murmurs or nods, and the procedure goes on. There's been an announcement that the time out was done, but no one was really engaged in it. I've personally seen 2 instances where just after the time out was performed, the surgeon asks the nurse if it had been completed yet. That's a problem of engagement.

Staff should stop what they're doing during time outs. In those 2 instances, the surgeon was too busy prepping the patient to even notice what was going on. You should also require that communication be done in active voice. Don't say, "This is Mrs. Jones," say, "What is the patient's name?" That's true for when you talk to patients, too. The other thing we find very helpful — although we rarely see it happen — is for the surgeon to explicitly say during the time out, "If you see a problem or have a concern, please speak up." Surgeons have a reputation, not always justified, of intimidating people. By explicitly saying, "Please watch my back," they're not only empowering staff to speak up, but also reducing their chances of making a mistake.

Q What's your outlook for wrong-site surgery?
Since 2010 we've seen a decrease in reported wrong-site surgeries of about 40%. They've been dropping every year, albeit slower and slower each year. The Universal Protocol started in 2004, and was the first real effort to solve the problem, but it hasn't completely yet. In 2007 we studied why, and found that it's not that it doesn't work, it's that it has to be done properly to work.

This really is something that we want to tackle and eliminate. Compared to other mistakes that happen in the OR, there really is no patient or disease that wrong-site surgery can be attributed to. It's something with known solutions. The number should be zero.

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