Any surgery performed at the wrong site, on the wrong patient or with the wrong procedure exacts a heavy toll on a patient's life, a surgeon's career and a facility's reputation. It's undeniable that human factors introduce the potential for error into every process, even carefully planned processes. But wrong-site errors are ultimately preventable, and must remain so. Here's how you can keep wrong-site surgery prevention a chief priority in your ORs.

Cause and effect
In my work as a healthcare quality consultant, I often cite a study that analyzed nearly 2,500 human errors that triggered events in complex industries. Eighty-one percent of those errors involved at least one of the following 10 conditions:

• time pressure,
• distractions,
• high workload,
• first-time learning curve,
• first working day after time off,
• working one half-hour after waking or a meal,
• vague or incorrect guidance,
• overconfidence,
• imprecise communication and
• work stress.

How many of those conditions exist at your facility? Most of them, I'll bet. I'd even venture to say that "overconfidence" may be the biggest pitfall in healthcare facilities. "It's not going to happen here" is a misconception that caregivers can easily fall victim to. This illusion puts too much trust in a surgeon doing a caseload of routine procedures and leads staff to blindly follow procedures without questioning out-of-the-ordinary situations. This illusion can be particularly problematic in a fast-paced facility that must keep a constant eye on the clock or work short-staffed. Many facilities have unfortunately discovered that wrong-site surgery "can happen here."

The basics
The persistent problem of wrong-site surgery has led the Joint Commission for the Accreditation of Healthcare Organizations, the American Academy of Orthopaedic Surgeons and other regulatory and professional groups to formulate and endorse patient safety protocols designed to stop wrong-site errors from occurring.

These protocols share redundant safeguards that identify and validate the patient and procedure before surgery begins.

• During a pre-operative verification stage, documents are reviewed and details are repeatedly checked between the patient and each member of the surgical team he encounters. You must investigate any missing or conflicting information.
• The surgeon, with the patient's involvement, marks the surgical site clearly and unambiguously. The doctor's initials or signature or the word "yes" are acceptable markings. An "X" is not acceptable. You may affix adhesive labels to the skin, but only as an addition to proper markings.
• Immediately before the surgery begins, take a time-out, during which surgical team members confirm patient identity, procedure and site. No action is taken until the team reaches an unquestionable confirmation.

Safeguarding the safeguards
If these steps are undertaken inconsistently, inattentively or without the full participation and input of the surgical team, however, they're no more effective than having no preventive measures in place at all.

Adopting a wrong-site surgery prevention protocol at your facility will make it official. Meetings and discussions can make sure that its steps are incorporated into the preparations for surgery. Getting surgeons and staff to think carefully and deliberately about the process each time they carry it out, though, may be the greater challenge.

Even a checklist designed to ensure that each step has been done, for example, can lead to a false sense of security simply due to the human-error potential that exists in routine tasks. If a staff member happens to autopilot their way through a checklist on the same day that a surgeon hurriedly signs off on a double-check because the checklist assures him it's been taken care of, a surgical error is a very real possibility.

I'll admit, I don't know how to make people think. But to improve your facility's patient safety environment you'll have to address both the needs of the surgical process and the individuals working within it to make them both more effective.

Could this happen here?
Perhaps the biggest challenge in preventing wrong-site surgery is overcoming complacency. In health care, we rely on our people to do their jobs right every time. Fortunately for us, the overwhelming majority of the time they do. But then we risk becoming complacent. "We've never had a wrong-site surgery here," we tell ourselves. "We do everything right, just like JCAHO tells us to do."

A culture of safety can't simply rely on people doing something perfectly every time. It has to expect that people will make mistakes. Hold a meeting of all your surgical players to talk about errors that have occurred at other facilities. Ask your staff, "Could this happen here? How? What would have to happen for this to happen here?" In this way, you'll be better able to identify and resolve your own facility's problems and potential errors.

As this discussion raises awareness of safety problems, be sure to invite surgeons and staff to add their own concerns, experiences and suggestions. Their input can make the difference between a prevention policy that they have an interest in carrying out and one that they see as an intrusion.

Make it known
Simple, clear and concise patient safety policies will create an expectation of procedural consistency and make it easier to do the right thing every time, which is an important step in reaching compliance.

Also, make sure every member of your surgical team is trained in the policies. Norfolk, Va.-based Sentara Healthcare has a system of what it calls red rules, with which compliance must be exact and verbatim. These rules include verifying and matching patient identification using two sources before taking any action; never mixing chemicals; and always plugging ventilators into red emergency outlets. If the conditions of these rules are not met, all action must stop until the situation is resolved. And if it's not resolved correctly, the responsible party will be disciplined.

Sentara doesn't have a lot of red rules, but the ones it does have are carved in stone, and every employee is accountable for them. With regard to wrong-site surgery prevention, I don't think it's going too far to say that the final time-out to verify each patient, site and procedure is an absolute rule that new employees should be aware of on their first day at the center. And remember to hold people accountable through clear action - counseling, warnings, peer reviews or sanctions, for instance - for non-compliance. The worst thing that can befall a safety program is an administration that doesn't hold people accountable for complying with critical human actions, such as following with all steps of the time-out procedure.

Speaking up
Preventing wrong-site surgery completely depends on assertiveness. In a culture of safety, everyone must be empowered to stop the procedure for additional verification if they sense a potential error that could endanger the patient.

This may be difficult for some staff members to do. I'm not convinced that everyone is brave enough to speak up, whether to a surgeon or to her peers. That's a symptom of a flawed environment. It's an obstruction to safety, and it needs to be fixed.

The repair should begin at the top. Staff will be more confident in speaking up if they know that their supervisors will back them, even if they're mistaken in their concerns. Management should embrace assertiveness in the name of safety. In Sentara's red rule system, when an employee on the front lines calls work to a halt on the basis of a rule, top management always supports this decision.

Unsafe supervision leads directly to unsafe conditions and unsafe acts. In the outpatient surgery field, productivity often takes center stage. If you value productivity over patient safety - or if the staff perceives that you do - the staff may not feel as comfortable speaking up to take action.

If, on the other hand, you're dedicated to improving patient safety, your staff will also be dedicated. You need to model the behavior that you expect from your staff in order to reinforce it.

The human focus
It's an occupational hazard: we tend to divorce ourselves from the fact that our patients are human beings. While it may be hard to maintain the human focus in the OR, it's essential to patient safety.

I'm the first to admit that the closer I get to Medicare age, the more important patient safety is to me. But most likely we'll all be patients at some time in our lives. Remember to think like a health care consumer, not just a manager. Next time, you might be the one relying on health care professionals to do the job right.