ASC nightmare: Wrong-site surgery & what to do about it

To err is human. However, in the healthcare industry, with people's lives hanging in the balance, there is little space for error.  One of the most unfortunate, albeit common, preventable medical errors is wrong-site surgery.  

Even today, wrong-site surgery is surprisingly common, despite the fact that the industry has developed processes to help prevent it, such as using checklists. However, in the first six months of 2013, wrong-patient, wrong-site or wrong-procedure surgery was the most common sentinel event category reviewed by The Joint Commission — 60 of the 446 sentinel events reviewed from January to June of 2013 were wrong-site surgery.

According to an Accreditation Association for Ambulatory Health Care patient safety toolkit — in 2012 there were 0.27 wrong-site, wrong-side, wrong-patient, wrong-procedure or wrong-implant surgeries per 10,000 ASC admissions.

Why does wrong-site surgery still happen?  Kathy BernickyAccording to Kathleen Bernicky, RN, the director of clinical operations at Regent Surgical Health, the answer is simple — complacency and hurrying. "Errors happen when complacency sets in and healthcare providers don't take the time-outs seriously. The RN circulator completes the formal checklist and calls the time-out, but the surgical team, doesn't always stop and participate" she says.

Some healthcare providers tend to think it won't happen to them, Ms. Bernicky added, and that line of thought can have dangerous consequences. Mistakes happen all the time, and there is no healthcare facility or provider who is immune.

Mistakes resulting in wrong-site surgery can range from failing to validate that the procedure on the consent is the correct procedure to failing to complete a safe surgery checklist, says Michelle George, RN, MSN, CASC, vice president, clinical services at Surgical Care Affiliates.

Additionally, ASC staff members can sometimes experience intimidation from surgeons. They feel pressured to complete their preoperative work faster, according to Ms. Bernicky, and this causes them to make mistakes. "They may take short-cuts and do an incomplete time-out. This can lead to a number of wrong-site surgery situations, including placing the surgical block in the wrong place or implanting the wrong intraocular lens," she says.    

Preventing wrong-site surgery
There are several steps ASCs can take to ensure that wrong-site surgery does not occur at their facility. Here are five key strategies:

1. Ensure thorough completion of the preoperative processes. According to Ms. George, one of the most important aspects of preoperative care that could lead to wrong-site surgery if overlooked is the verification between the scheduling requests from the surgeon's office and the surgical consent to ensure a correct match. "This process is not complete until the surgical procedure has been validated with the patient during the preoperative assessment period," she says.

Another preoperative procedure often overlooked or done carelessly is the marking of the surgical site. To avoid the possibility of wrong-site surgery as a result, the surgeon, in collaboration with the patient, should mark his or her initials on the operative site with a permanent marker, says Ms. George. The operative site can then be noted by the OR team as part of their timeout process to ensure everyone knows where the surgical site is.

2. Implement a specific time-out process. Having a specific process in place for time-outs is important. "The final time-out process should be the same for every patient, every time. An example would be a time-out that is 60 seconds long. One member of the surgical team, typically the anesthesiologist holds up a big sign to signal the beginning of a time-out. At that point, the entire OR staff should stop what they are doing. The RN circulator is responsible for making sure a proper time-out is completed immediately prior to the start of the procedure," says Ms. Bernicky. "Time-outs [that] I've observed can be as quick as 10 to 15 seconds. This doesn't give the surgical team enough time to stop what they're doing and participate."

Surgery center staff can practice and review their time-out process on a regular basis. "I've been teaching ASCs about the time-out process for a long time, and 50 percent of the time time-outs are not adequate in my experience," adds Ms. Bernicky.

3. Gain buy-in from ASC leadership. Both inside and outside the operating room, it is important that ASC leaders focus on constant quality improvement. "Medical directors should be actively participating in quality improvement and support the leadership staff," says Ms. Bernicky. "Inside the OR, ASC leadership needs to give staff members specific tasks to ensure that processes such as checklists and time-outs are being completely in an appropriate manner."

For example, one team member is put in charge of checking the two patient identifiers. Also, anesthesiologists are made accountable for ensuring all staff have stopped what they're doing, the surgeon reads the procedure from the consent, the surgical tech is responsible for stating the site marking is visible after draping and the RN circulators complete the checklist, suggests Ms. Bernicky.

Additionally, ASC leadership needs to be invested in conducting ongoing audits, followed by immediate intervention and education if they observe noncompliance issues.

4. Utilize technology-based monitoring. ASCs can incorporate low-resolution cameras in their OR allowing leaders to watch OR procedures remotely, in real-time. If the administrators or nursing leaders see that staff members are noncompliant, they can intervene immediately, says Ms. Bernicky.

"I really like the cameras," she adds. "You can't identify the patient and or the staff member because the cameras are low-res, but you can identify the processes and see whether or not they are being followed."

5. Continually educate staff members. "ASC leaders should ensure an environment of transparency where information about actual or near miss patient harm events are openly discussed and team members are comfortable speaking up," says Ms. George. Protocols and policies are only effective if consistently applied by all team members for all patients all of the time.

ASC administrators can discuss the issue in meetings and circulate information about wrong-site surgery as well as encourage questions, says Ms. Bernicky, to help staff understand the importance of facility policies and work processes to prevent errors.  

Worst-case scenario
However, wrong-site surgery could occur despite stringent efforts to avoid it. Here are four steps ASCs can take to mitigate the effects of wrong-site surgery:

1. Inform the necessary people/authorities. Inform the patient and patient's family immediately as well as regulatory authorities in the state and accreditation organizations when wrong site surgery occurs, says Ms. Bernicky.

2. Encourage open communication among team members. It can be devastating for the team when a facility experiences a wrong-site surgery situation; communicate openly with staff and involve the team in finding solutions.

"My advice is for the team to identify all possible contributing causes to their specific wrong-site surgery and to implement strategies that ensure consistent application of patient safety practices," Ms. George says. "Communicating and celebrating the elimination of wrong-site surgery is critical to the team's morale and keeping the commitment to patient safety alive and well."

3. Perform a "root cause analysis." Root cause analyses can help surgery centers determine when and how the process breakdown occurred. "After conducting the analyses, implement a plan of correction and begin re-educating staff and physicians. Also change processes or process implementation strategies to make sure it doesn't happen again," Ms. Bernicky says.

4. Avoid playing the blame game. Ultimately, strong teams can prevent wrong-site surgery and effectively deal with repercussions if it does happen. "When something like this happens, you don't want to do any finger-pointing," says Ms. Bernicky. "The tendency is to blame this person or that, but you need to look at the process and ask yourself 'where did it fail?'"

Ms. Bernicky also suggests bringing in an outside consultant to look into an ASC's work processes. "When they come in, they may be able to see something you can't see," she says.   

More articles on quality:

The importance of improving pain management in ASCs providing higher acuity procedures
ASC QI project success: The 4 'E's that drive process standardization
Wolters Kluwer Health teams with AAACN on ambulatory nursing software

Copyright © 2024 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.

 


Patient Safety Tools & Resources Database

Featured Webinars

Featured Whitepapers

Featured Podcast