8 Strategies to Prevent Wrong-Site Surgery

Seven years after the Joint Commission first unveiled mandatory rules to prevent operations on the wrong patient or body part, researchers and experts say the problem of wrong-site surgery has not improved. Based on state data, Joint Commission officials estimate that wrong-site surgery occurs 40 times a week in U.S. hospitals and clinics, with 93 cases of wrong-site surgery reported to the accrediting organization in 2010.

The results of wrong-site surgery can be devastating for patient, physician and facility alike, hence the push by accrediting and patient safety organizations to make this issue a "never" event. Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, executive director and CEO of AORN, discusses eight strategies to prevent wrong-site surgery at your facility.

1. Validate information on side and site the night before surgery. Ms. Groah says the evening before surgery, a staff member should validate the information needed for the next morning. This prevents last-minute panics and gives the patient a chance to confirm the surgical details. "Many hospitals will actually do a telephone interview the night before with the patient just to confirm the instructions, so they know the patient will be ready for surgery the next day," she says.

In some cases, the patient may be frustrated with having to give the same information multiple times, but Ms. Groah says the provider should simply reassure the patient that repetition is necessary. "The answer is that these are measures of safety we put into place to make sure your surgical procedure proceeds uneventfully," she says.

2. Pre-operatively, make sure all documents agree on the side and site of surgery. Prior to surgery, a staff member should look at all documents related to the surgery to make sure the information about the surgical site matches up. She says the staff member would check the informed consent form, signed by the patient, as well as the procedure on the typed schedule and the physician's note written pre-operatively about the procedure. Any inconsistencies should prompt a conversation with the physician and the patient about the correct site of surgery and best way to proceed.

3. Require the surgeon performing the procedure to mark the site. Ms. Groah recommends that the surgeon mark the surgical site with an X or his or her initials prior to surgery. She says assigning this task to the surgeon increases his or her accountability and standardizes who performs the task throughout the organization.

"The person performing the procedure basically has the responsibility and accountability for the patient and for the procedure that's being done," Ms. Groah says. "They're being held accountable to do the procedure and should be the one that actually partners with the patient to mark the side and site." Ms. Groah says studies have shown that instances of wrong-site surgery do increase significantly when the site is marked by a provider other than the surgeon performing the procedure.    

4. Institute "red rules" that allow any staff member to stop the surgical process. During the time-out prior to surgery, team members confirm the side and site of surgery (preferably with the patient) and the surgeon marks the location. "The critical thing here is that everything stops and everything is focused on the patient and what you're about to do," Ms. Groah says. She says if there is any hesitance from a team member, the surgical process should stop — a policy she calls "red rules."

"Red rules mean that anybody on the team, when they see something that's not consistent with standards of practice, has the authority to call the 'red rule' and stop whatever's happening until it's resolved." She says it's important to instill the culture of "red rules" in the OR during safety training. Physicians and other providers should be reminded that no one is allowed to ignore the red rules per facility policy.  

5. Train all staff members on the use of a surgical checklist. Every operating room should utilize a surgical checklist to prevent errors such as wrong-site surgery, Ms. Groah says. The concept of surgical checklists originated with the airline industry, which introduced checklists for use before flights after a number of accidents caused by human error. "There are so many significant things that need to be done pre-procedure and prior to incision — there are so many steps," Ms. Groah says. "Forgetting any one of those could lead to a disastrous outcome."

She says the circulating nurse is generally assigned the work of checking off items on the checklist, during which time everything in the OR should stop. She says OR team members should undergo orientation on how to use checklists, and hospital administration should encourage staff to take the checklists seriously. "There are some people who take the checklist and check it off and get cavalier about it rather than actually going through the process," she says. She says every facility should have a no-tolerance policy for this attitude: "I had the opportunity to work with a chief of surgery who said, 'If you don't use the checklist appropriately, you don't want to operate here,'" she says.

6. Involve the patient in marking the side and site. Ideally, Ms. Groah says the patient should be kept awake during the checklist process to confirm the correct side and site of surgery. The patient will likely feel more confident in the facility's safety if they are involved in confirming the correct surgical location.  

7. Share incidents with wrong-site surgery throughout the facility. Ms. Groah says some staff members may not appreciate the significance of preventing wrong-site surgery because they have never experienced a surgical error. She says while it's not necessary to point fingers at those who make mistakes, the facility should share instances of wrong-site surgery or other surgical errors throughout the hospital to emphasize the importance of safety policies.

"If there is an unusual occurrence and a wrong-site surgery, the drilldown on that critical event can be pretty devastating," she says. "It's important to share those significant events — not necessarily who did it, but how the patients were mixed up or how the wrong-site surgery was performed — to prevent it from happening in the future."

8. Sample random procedures to determine checklist compliance. Instituting a policy around wrong-site surgery is relatively useless if no one follows it. To make sure your staff members are using their checklists, asking the surgeon to mark the site and involving the patient in the process, Ms. Groah recommends choosing random procedures and observing the pre-operative time-out. She says this information should be tracked over time to determine whether compliance is improving and how that compliance relates to surgical error rates.

Learn more about AORN and the AORN Commit to Time Out Campaign.

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CMS Releases Proposed Quality Reporting Guidelines for ASCs

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