Wrong Site Surgery – How the Heck Does That Happen?

About 100 times each year the unthinkable happens- surgery is performed on the incorrect patient, or the surgery is on the correct patient, but on the incorrect side.  The outcome can be devastating – the wrong limb amputated, the wrong breast removed, or a hysterectomy on an incorrect patient.

When the unthinkable does occur, research shows that there are usually a number of process errors that take place, rather than a single person making a single mistake. Additional research has shown that healthcare professionals sometimes don’t feel empowered to speak up in situations like this, even when they believe something is wrong.
Because of the possible severity of the outcome, the Joint Commission and other leading healthcare organizations have implemented a Universal Protocol that includes three specific components:
• Verification of the patient’s identity and the surgery scheduled
• Marking the surgical site,  and
• A “Time Out” process prior to surgery.

These three items are now a Joint Commission requirement for all accredited facilities.

I recently saw the first criteria, verification of the patient’s identity in action. I went with a friend of mine to the hospital where she was having minor surgery performed.  Prior to surgery the pre-operative nurses confirmed her identity, and checked her wristband against the information she told them. She also met with her surgeon, who confirmed her ID again, and verbally confirmed the expected surgical procedure. Following his visit, separate visits from the perioperative nurse and the anesthesiologist took place. Each one checked my friend’s arm band, verbally confirmed both her name and birthdate, and asked her what surgery she was expecting. The benefit of these visits is not only increased comfort on the patient’s part, but the key members of the surgical team had met the patient prior to going to the operating room.

Marking the surgical site is required if the surgery is on one side of the body, as in a left or right leg, arm, eye, ear, etc. In many organizations, patients “sign their site”. When a patient does this, they use a permanent marker to place their signature on the surgical site. For example, if you have having surgery on your right knee, you would “sign” your right knee. This provides one more safeguard so that the correct surgery is performed.

The “Time Out” is the last safeguard for the patient. During the “Time Out”, which takes place prior to the initial incision,  each surgery team member of the team verbally clarifies that the patient is who they think he is, the surgery is correct and the correct side of the body is identified. Each member has to verbally agree, and if any member has a concern, they are encouraged to speak up and present that concern.
One of the best practices you can embrace is the Universal Protocol – it is a key element of patient safety, and protects you and your patient!
Joint Commission - www.jointcommission.org
Association of periOperative Registered Nurses - www.aorn.org
American Academy of Orthopedic Surgeons – www.aaos.org