6 Steps to Prevent Wrong-Site Surgery

In June, the Joint Commission Center for Transforming Healthcare reported that despite intense efforts to curb wrong-site surgery, the adverse event still occurs approximately 40 times a week nationwide. Wrong-site surgery — which includes wrong procedure, wrong patient, wrong side and wrong site — was the third most common sentinel event reported in 2010. Linda Groah, CEO of AORN, discussed six ways hospitals and ambulatory surgery centers can prevent-wrong site surgery.

1. Lead a campaign around wrong-site surgery throughout the facility. Ms. Groah recommends hospitals and surgery centers push for wrong-site surgery prevention by holding a campaign that involves every level of the facility. "When I talk about patient safety from the CEO perspective, it has to permeate the organization from the top down," she says. This means that administration should bring up wrong-site surgery at staff meetings, participate in safety rounds and note progress toward wrong-site surgery prevention in employee newsletters, CEO blogs or on the facility intranet.

Facilities can support wrong-site surgery prevention with the rest of the healthcare industry by participating in National Time Out Day, a June 15 holiday that aims to remind the entire surgical team of the importance of time-outs before surgery. Of course, prevention efforts should not start and end on June 15; administration should roll wrong-site surgery prevention into overall patient safety goals throughout the year.

2. Implement a checklist. Ms. Groah says AORN has seen strong improvements in wrong-site surgery prevention in facilities that implement a checklist. "The use of a checklist actually identifies everything that needs to be done for the patient pre-operatively, including marking the side and site of the surgery," she says. She indicated that generally, the operating room circulating nurse is in charge of the checklist, though the surgeon or lead provider is responsible for marking the site and side of surgery. Since operating rooms can be noisy and distracting environments, she says some organizations enlarge the poster and attach it to the wall so that every provider can watch the circulating nurse check off the essential steps.

Ms. Groah adds that wrong-site marking is part of the Joint Commission's Universal Protocol requirement. "This is one way to actually get across to people that if you don't do this, there are ramifications from the perspective of regulations." AORN provides a checklist in two versions — a PDF and a customizable word document that providers can tweak based on the type of case. For example, a cardiac case might include different steps than a seven-minute cataract surgery. The AORN list is color-coded and designates which steps are Joint Commission criteria, World Health Organization criteria and SCIP measures required by CMS.

3. Watch for miscommunication during hand-offs. Ms. Groah says a checklist can also help providers communicate during patient hand-offs. "I might go on my lunch break, and the nurse that is relieving me may assume that something has been done," she says. A checklist will let the next provider know that the site of surgery has not been checked prior to incision.

4. Involve the patient in marking the site and side. Ms. Groah recommends providers talk to the patient before marking the site and side of surgery. This might mean saying, "Ms. Jones, we're going to be operating on your left knee today, and I'm going to mark it now. Is that correct?" She says some physicians will put more responsibility on the patient by asking, "Which knee am I going to do today?" to make sure the patient doesn't simply agree with the physician's assessment because they are intimidated. The difference between these two questions depends on the patient's level of education and cognition, she says.

5. Think outside the operating room. Ms. Groah indicates that some facilities concentrate their wrong-site prevention efforts on the operating room and forget about other areas of the hospital. "Wrong-site surgery does not only occur in the operating room," she says. "There are chest tubes and surgical procedures that are done in the intensive care unit, emergency room and other departments, and interestingly enough, they frequently think they don't have to abide by wrong-site surgery protocols." She says organizations should encourage prevention efforts throughout the facility, taking time to emphasize that departments where surgery does not traditionally occur are not exempt.

6. Involve every team member — physicians included. Some providers may be hesitant to implement a time-out or a checklist because they feel impervious to errors. Physicians might say, "I have been operating for 25 years, and I've never performed a wrong-site surgery," Ms. Groah says. In these cases, hospitals and ASCs should present data on the rates of wrong-site surgery and allow staff members to give testimonials about their experiences with adverse events.

These testimonials and statistics can give administration some leverage in pushing for a campaign. Ms. Groah cited a statistic that showed over 90 percent of physicians said they would want their surgical team to use a checklist if they were undergoing surgery themselves — a much higher percentage than said they used a checklist while performing surgery.

Learn more about AORN and the comprehensive surgical checklist.

Related Articles on Patient Safety:
15 Self-Reported Factors for Poor Adherence With Hand Hygiene
Delivering Respiratory Care Without Spreading 'Bugs'
Dr. Steele: Make Patients, Families 'Co Pilots' in Managing Their Care

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