Wrong Site Surgery

Preventing Wrong-Patient, Wrong-Site, Wrong-Procedure events requires proactive measures. Take action now to prevent and reduce these sentinel events from occurring.

Sentinel Events: Prevention and Reduction of Wrong-Patient, Wrong-Site, Wrong-Procedure Events

Objectives

• Review the evidence-based recommendations to prevent and reduce the incidence of wrong-patient, wrong-site, wrong-procedure events.
• State actions to prevent and reduce the incidence of wrong-patient, wrong-site, wrong-procedure events.
• Identify ways in which wrong site surgery injuries present themselves from a legal perspective.
• Identify common errors that result in wrong-site injuries.

Components

• Faculty Disclosure (PPT)

Resources

• Actions to Prevent Wrong-Patient, Wrong-Site, Wrong-Procedure Events
• AORN Correct Site Surgery Tool Kit
• AORN News Wrong Site Surgery Events
• Articles and Websites Wrong Site Surgery
• Definitions related to Wrong Site Surgery
• Surgical Triggers - Articles and Websites - Wrong Site Surgery

Checklists for Operative and other Invasive Procedures:

• American Society of Ophthalmic Registered Nurses (ASORN) Ophthalmic surgical checklist
• AORN Comprehensive Surgical Checklist
• Sample Checklist - Cardioversion Checklist
• Sample Checklist - Ophthalmology Checklist
• Sample Checklist - Presurgery Safety Checklist
• The American Society for Gastrointestinal Endoscopy - Gastroenterology safe surgery checklist for ambulatory surgical centers

Time Out Day

• National Time Out Day to be Recognized by The Joint Commission and AORN
• Time Out Process Video Clip
• Sample - A letter to Health Care Administrators
• Sample - A letter to Perioperative RNs from AORN and The Joint Commission
• Sample - A time out day alert

The Universal Protocol:

• Sample Policy - Verification of Correct Patient, Procedure and Site/Side
• Sample Policy - The Universal Protocol
• The Joint Commission Universal Protocol
• Quality and Process Improvement
  
• Sample - Audit Tool Post Implementation of a Surgical Checklist
• Sample - Debriefing
• Sample - Healthcare Failure Mode and Effect Analysis US Department of Veteran’s Affairs Healthcare Failure Mode and Effect Analysis (HFMEATM)
• Sample - Learning Board in Action
• Sample - Proactive Risk Assessment for Surgical Site Validation

Professional Organizations

• American Academy of Ophthalmology Wrong Site Task Force Recommendations
• American College of Surgeons: [ST-41] Statement on ensuring correct patient, correct site, and correct procedure surgery
• American Society for Healthcare Risk Management: Healthcare Risk Management Solutions for Top Reported Sentinel Events Tip 5: Sign Out Wrong-site Surgeries
• Association of periOperative Registered Nurses (AORN) Position Statement Preventing Wrong-Patient, Wrong-Site, Wrong-Procedure Events
• The American College of Obstetricians and Gynecologists: Committee Opinion Patient Safety in the Surgical Environment

Patient Safety Organizations

• Agency for Healthcare Research and Quality
• Institute for Healthcare Improvement
• Patient Safety Advisories - Patient Safety Authority Commonwealth of Pennsylvania
• Safe Surgery 2015
• The Joint Commission Center for Transforming Healthcare (PDF)

US Federal Agency Websites

• Centers for Medicare and Medicaid Services Evidence-based Guidelines for Selected Hospital-Acquired Conditions (PDF)

Video Clip

• Sample Video - Reducing the Risk of Wrong Site Surgery. The Joint Commission Center for Transforming Healthcare

Copyright

Copyright © 2014 AORN, Inc. All rights reserved. Except as noted herein, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without prior written permission from AORN, Inc. Users are not permitted to use this content for commercial purposes. Users are permitted to copy and paste content and adapt it for use in their work settings. Permission for other uses may be sought directly from AORN, Inc., located in Denver, Colorado (USA), by contacting the Publications Department by email ([email protected]) or by fax 1-303-750-3441. NOTICE No responsibility is assumed by AORN, Inc. for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any standards, recommended practices, methods, products, instructions, or ideas contained in the material herein. Because of rapid advances in the health care sciences in particular, independent verification of diagnoses, medication dosages, and individualized care and treatment should be made. The material contained herein is not intended to be a substitute for the exercise of professional medical or nursing judgment The content in this publication is provided on an as is basis. TO THE FULLEST EXTENT PERMITTED BY LAW, AORN, INC. DISCLAIMS ALL WARRANTIES, EITHER EXPRESS OR IMPLIED, STATUTORY OR OTHERWISE, INCLUDING BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, NON-INFRINGEMENT OR THIRD PARTIES RIGHTS, AND FITNESS FOR A PARTICULAR PURPOSE.