3 Fixes to Prevent Wrong Site Surgery

3 Fixes to Prevent Wrong Site Surgery

June 5, 2022

A wrong site, wrong patient, or wrong procedure surgery may not have happened on your watch, but no periop team is immune to one error within preoperative activities that can result in wrong surgery.

Unfortunately, more patients are paying the price for teams who let safety errors slip through the cracks, according to the latest sentinel event data from The Joint Commission.

In 2021, 85 wrong site surgeries were reported, up from 68 in 2020, and 52 in 2019, and these reported sentinel events only represent an estimated 2% of actual wrong site surgeries.

The Joint Commission says this significant jump in wrong surgeries signals a call to action for every periop team member to make sure their Time Out is working to catch an error before incision.

Based on findings from Joint Commission surveyors, the number one reason surveyed teams had issues with the Time Out was when some team members were continuing with other tasks during the Time Out, according to Lisa DiBlasi Moorehead, EdD, MSN, RN, CENP, associate nurse executive of Accreditation and Certification Operations for The Joint Commission.

However, DiBlasi Moorehead says such mistakes can be fixed by focusing on three key solutions:

1. Leadership Must Instill a Culture of Safety

Leaders have a responsibility to create safeguards such as the Time Out that catch wrong surgeries, but these safeguards only work in an environment where staff feel psychologically safe enough to speak up when they see risks, including colleagues not participating in Time Out.

2. Staff Must Engage in Every Time Out

Staff must be accountable to participate fully in the Time Out and other safeguards to prevent wrong surgery. When fully engaged, staff are more likely to notice a safety risk they can call out to prevent patient harm.

3. Teams Must Improve Communication

Breakdown in communication is well recognized as a key reason for wrong surgeries, but teams can change this by working to build strong communication skills together in the OR on all fronts.  Each team member has a unique perspective on safe patient care that is strongest when communicated through team interaction.