Cataract surgery teams have it easy when it comes to marking the site right. Or is it left? Ophthalmic surgeons who take a blind stab have a 50% chance of cutting into the correct eye, but right-side surgery shouldn't come down to a coin flip. At Vermont Eye Surgery & Laser Center in Burlington, multiple layers of checks and quintuple checks all but guarantee it doesn't. Here's a look at the standardized steps staff there follow to ensure sites are marked correctly.

• The process to confirm the correct eye should begin with ensuring the information received from surgeons' offices is correct, says Mary Clairmont, RN, the facility's clinic administrator. If it's not, multiple checks in place will simply confirm wrong information.
• Have nurses who contact patients a week before scheduled procedures ask the patients to confirm on which eye the surgeon will operate.
• Make sure your facility's scheduler gathers the patients' consent forms and operative notes, and ensures the information contained in each matches the eyes noted on case booking sheets. Include the paperwork in patients' charts.
• In pre-op, if the patient's name, procedure and eye match what's noted in the chart, have staff place a "L" or "R" sticker above the corresponding eye and tape a clear plastic shield over the non-operative eye.
• When the surgeon meets with the patient in pre-op, he should discuss which eye he'll operate on, doublecheck the paperwork and sign his initials next to the sticker.

The process doesn't end there. Ms. Clairmont says the circulating nurse confirms the correct eye with the patient when she arrives in pre-op and the anesthesia provider does the same when he explains the retrobulbar block he's about to place. A pre-op time out is performed in the operation room, during which the staff and surgeon refer to the booking sheet to once again confirm the correct eye.

Joint Commission surveyors have given the process rave reviews, says Ms. Clairmont, "because it was consistent for every patient. The surveyors were here for a couple days, followed patients into the operating room and would see that we followed the same approach to marking the correct eye before each and every procedure."

Individualized patient care is important for satisfaction scores, but not site marking. The process in place at Vermont Eye was designed for cataract surgery, but its fundamental principles — a standardized, learned script — can serve as a lesson for any surgical team in any type of facility. "You hear all of us saying the same things, asking the same questions to every patient before every case," says Ms. Clairmont.

That's not to say the process is executed perfectly every time. No process is. But the beauty of implementing multiple checks into the site-marking process is that inevitable miscues are less likely to result in a wrong-site surgery. When gaps in protocols do occur, address them immediately.

Operating on the correct eye shouldn't come down to a coin flip.

If, for example, an anesthesia provider at Vermont Eye administers a block before the surgeon had a chance to visit with the patient and confirm the correct eye, the team gathers to figure out why. "We get everyone who was involved in preparing the patient for surgery to sit around a table and discuss what happened in a non-punitive way," says Ms. Clairmont. "We simply want to know how it happened, how our process failed and how we can fix the issue so it doesn't happen again."

Leopoldo Rodriguez, MD, FAAP, FASA, vice chair of the American Society of Anesthesiologists Committee on Ambulatory Surgical Care, says his home state of Florida saw a spike in wrong-site surgeries 2 years ago. Providers from professional groups who gathered at a summit called to address the problem spent a significant amount of time discussing how to ensure surgeons operate and anesthesia providers place blocks where they should. Dr. Rodriguez recently shared a few recommendations he raised at the summit, including:

• In pre-op, ask the patient to confirm the intended operative site. Make sure what the patient says matches what's noted in the surgical paperwork. If there's a discrepancy, immediately call the surgeon to the patient's bedside to confirm the correct site.
• Also in pre-op, have the patient mark the correct site with an "X." Then have the surgeon sign his initials — dark purple ink shows clearly on all shades of skin, says Dr. Rodriguez — near the X after discussing the planned surgery with the patient.
• If a nerve block is scheduled, the anesthesia provider should note his initials next to the surgeon's mark.
• Involve the circulating nurse in the marking process, so a representative from the OR team has observed the site marking and brings that knowledge to the pre-op time out when the correct site will be confirmed once again.
• Perform the time out before administering anesthesia so patients can actively participate in confirmation of the correct site.

Dr. Rodriguez also suggests referring to the surgical consent, not the surgical schedule, when confirming the correct site, because it contains the most accurate information about the planned procedure.