While it's still considered a rare occurrence, wrong-site surgery is probably the most common of the serious preventable medical errors that occur. The damage can be dramatic and the aftermath potentially life-changing. As the following case illustrates, it may also indicate a deeper quality control problem within a healthcare organization.

Experiencing increased lethargy after a fall, a man, 86, was admitted to a Rhode Island hospital's emergency room. A CT scan revealed a buildup of blood between the patient's brain and the left side of his skull. After examination, the man was diagnosed with left-sided subdural hematoma. The patient was emergently transferred into the OR and the neurosurgeon began prepping for an emergency craniotomy. During the procedure the neurosurgeon operated on the wrong side of the patient's skull. When the neurosurgeon discovered the error, he immediately, and successfully, evacuated the correct side (left) and notified the patient's family. Hospital administration stated that while it does have policies and procedures in place to prevent an incident like this, it appeared as though at least one standard policy was not followed.

A demanding public
With the ability to effortlessly obtain access to current health practices, and even health grades, patients are increasingly less tolerant of mistakes and careless human error. As we've all observed, when an uncovered error becomes public, the healthcare organization becomes accountable for explaining the circumstances in painstaking detail.

Learning from other healthcare providers' mistakes can help us to make better decisions by observing the lapses in procedure and process. The following explanations, reported by the hospital and Rhode Island Health Department, explain how the wrong-site surgery occurred. Analyzing the events by the Rhode Island hospital staff offers a telling picture of the dangers that can occur when we don't follow policies.

The patient was brought directly from the ER into the OR. There was no indication of a pre-op nursing assessment.
There was a failed pre-op assessment in conjunction with the Joint Commission Universal Protocol. Before surgery, and before the patient leaves the pre-op area, a pre-op verification must take place. This includes the perioperative nurse verifying the patient's identification and confirmation of the surgical site with the patient and/or family. This process includes determining site laterality (right vs. left) if multiple structures (such as digits) are involved and if there is a specific level of the spine involved. The information the patient and family provide about the surgical site should match the patient's medical records, which include the consent form, patient history, physical, physician's orders and radiology reports.

The surgeon and surgical staff failed to make an accurate assessment of the correct location of the hematoma before performing the surgical evacuation.
Before the surgical procedure, the surgical team should verify that the patient's surgical site is marked per the organization's policy and indicates the correct surgical site. Per the Universal Protocol, the site must be marked so that it is clearly visible after the patient has been prepped and draped for surgery. The location of the patient's hematoma before surgery is crucial in determining a multitude of things involved in the surgical care of the patient. This includes, but is not limited to, performing surgery on the correct side and setting up the sterile field and operating room in the proper order to accommodate the patient's positioning.

The neurosurgeon reviewed the CT scan once, then operated from memory.
Intraoperatively, it is the surgical team's and the surgeon's responsibility to ensure the needed reference documents, such as scans and films, as well as the correct instruments, implants and special equipment, are ready for each patient before delivery of surgical care.

Communication between the ER, radiology and nurses was inadequate.
The importance of communication, especially in an emergency, can't be stressed enough. The receiving nurse should obtain an accurate nursing report in preparation for the transfer of care. Misinformation can lead to serious blunders. The 2007 Joint Commission National Patient Safety Goals require organizations to improve communication among caregivers by implementing a standardized approach to handoff communications, which includes an opportunity to ask and respond to questions. In order to decrease miscommunication, standard reporting procedure should be used whenever transfer of patient care occurs.

The consent for surgery, signed by the patient's family, didn't specify on which side the skull would be operated.
The perioperative nurse should review all patient consent forms for accuracy and completeness (signatures, dates and times) before the patient enters the OR. There should be confirmation that the diagnosis and procedure on the consent form matches what the patient/family has identified as the procedure and surgical site. This includes laterality, multiple structures and levels. The procedures listed on the consent form should match the surgery schedule and information listed in that physician's pre-op history and physical.

The staff failed to take a time out before incision.
The Rhode Island Health Department conducted a preliminary investigation and found that the surgery team failed to take a time out to conduct a final verification of the correct patient, procedure and site. Not completing a surgical pause isn't only a violation of hospital policy, but also of the Joint Commission Universal Protocol. If all parties on the surgical team don't agree to the information presented in the time out, the team must immediately take action to correct the error. This may involve re-prepping, redraping or repositioning the patient before incision. View the pause as one last safety check to verify the patient, procedure and surgical site.

Ensure that polices are followed
When an error like this occurs, it serves as a reminder that healthcare professionals, including nurses, are brought into litigation and lawsuits more frequently than in the past. It is a nurse's duty to question and alert the surgical team if we feel a patient's safety is compromised. An organization's culture of trust and respect will allow the nursing staff to feel empowered to notify the surgical team when they suspect a problem. In many instances this environment can be the key to eliminating errors. In this case, not performing the surgical pause and not checking the patient's identification violates not only the organization's policy, but also the standard of care of perioperative nursing. The Joint Commission Universal Protocol states that active involvement and effective communication among all members of the surgical team is important for success in preventing the wrong procedure and surgery on the wrong site or wrong person.