Guidance to Prevent Adverse Events in Surgery Centers: Wrong-Site Surgery

Wrong-site surgery is one adverse event that occurs with too much frequency in ambulatory surgery centers, says W. Jan Allison, RN, CHSP, director of accreditation and survey readiness, clinical services department, for Surgical Care Affiliates.

 

"The most common occurrence is with an injection for a block or local occurring on the wrong side or implanting the wrong intraocular lens implant during a cataract surgery," she says. "ASCs have standardized processes in place to conduct pre-verification of the correct site, mark it and do a final time out to pause and once again verify the correct site. But because blocks occur prior to the procedure, many of these processes are not utilized when a block takes place. Or the eye implant is not part of the verification process."

 

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For a block

To avoid the wrong side with a block, pre-verification of the correct site with the patient and medical record documents, site marking and a time out should be performed prior to the injection.

 

"Surgeons have injected a local into the wrong side prior to the time out while the OR team is prepping for the case," Ms. Allison says. "Injections should not happen without a time out of the procedure team."

 

For lens implants

To avoid the wrong side for lens implants, the specifications of the lens implant should be included in the pre-procedure verification and time out.

 

"Only that lens intended for that patient should be in the operating room," she says. "And when verifying the lens against the patient's paperwork brought by the physician from the office, verify the paperwork against the patient on the table to ensure the correct paperwork was brought into the room."

 

Full engagement is critical

Ms. Allison notes that many times, while a center may implement a time out, the team isn't always truly engaged. "They are simply going through the motions and their minds are not fully focused on the patient and the elements being verified during the time out," she says. "I compare it to times when we drive and our minds are elsewhere and while we manage to reach our destination safely most of the time, we don't even remember the last five miles of the journey.

 

Everyone on the team needs to have an active role in the time out in a way that gets them fully engaged. The timeout should extend to the point of incision or puncture so more than the physician is focused on the ensuring it occurs on the intended site.

 

"As humans, we need other teammates to put a focused eye on the actions of others, to give that help, that backup, to prevent errors that impact the safety of the patient," Ms. Allison says.

 

Learn more about Surgical Care Affiliates.

 

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