Wrong-Site Surgeries Should Be Never Events

Focusing on the clinical aspects of multiple complex procedures during a busy day of surgery is stressful for surgical teams, so it’s understandable that the basic steps needed to prevent wrong-site surgery might get short shrift. Understandable, but not acceptable, especially when it comes to making sure you have the right patient for the correct procedure performed on the proper part of their anatomy. One wrong-patient, wrong-side, wrong-site surgery is one too many. Here are the steps you can take to prevent one — and how to ensure they get the attention they deserve.

• Mark sites clearly. Imagine tracing your five fingers and your hand to make a picture of a Thanksgiving turkey like you did in kindergarten. Now ask yourself to identify the second digit. The answer could be your ring finger or your index finger, depending on which hand you traced and whether you counted from left to right or right to left.

This potential for confusion is why hand surgeries are prime candidates for a wrong-site surgery to occur, says James W. Bowers, BSN, RN, CNOR, TNCC, clinical nurse educator and service line coordinator for nine departments at West Virginia University Hospitals Inc. in Morgantown. “It’s very easy when you’re doing the timeout to say, ‘We’re going to work on the second digit from the right,’” says Mr. Bowers. “But if you turn the hand over, the second digit isn’t the correct one you marked. It’s the other second digit.”

That’s why it’s critical to mark the side you’re going to be working on, says Dawn Yost, MSN, RN, CNOR, CSSM, business manager of perioperative services at West Virginia University Hospitals Inc. If you’re going to be working on the dorsal side, that’s the side that needs to be marked. If the incision is going to be made on the palm, you must mark the palm side.

• Confirm before cutting. After the time out is completed, it’s important to reiterate where you’re going to be working right before the knife hits the skin. “Even though the surgeon has confirmed the site with the patient and the team confirmed the site during the time out, confusion can still occur once the patient is prepped and draped,” says Ms. Yost.

Visual contact should be made with the site mark during the time out and immediately before the initial incision. It’s also important to make sure the mark isn’t wiped off when the surgical site is prepped. The redundancy is important simply because so many things can go wrong after the time out, says Mr. Bowers.

For example, a team could get the site wrong when a patient’s extremity is placed on a positioning board or leg holder, and then the table gets turned 80 degrees. Also, a drape that shifts just before an eye procedure begins could mask part of the patient’s face and lead to a procedure performed on the wrong eye. Consider leaving the whole face exposed so the surgeon can readily see which eye is marked and place a dot above the brow of the eye that will be operated on, says Ms. Yost.

• When in doubt, stop. If scrub personnel or the circulator doesn’t believe it’s safe to proceed with a case, they should not hand the surgeon the knife. A nurse wanting to do another time out if a patient has been flipped and there is confusion about the surgical site is more than enough reason to call what WVU Medicine refers to as a “Condition Stop,” says Mr. Bowers.

Train new employees to do this because they might otherwise be afraid to speak up. “Tell them that calling a hard stop is a way of them being a patient advocate, and that it’s their job to protect patients’ rights, which don’t stop when they’re under anesthesia,” says Ms. Yost.

On the back end, management must back the nursing staff, even if after reviewing the matter it turns out that perhaps the procedure could have proceeded without incident. “Nurses can’t feel pressured,” says Mr. Bowers. “They have to know they’ll be supported the next time they want to call a Condition Stop.”

• Enhance time outs. Hang a large poster in every OR that includes all the information that is supposed to be verified during time outs. The posters serve as reminders for nurses, anesthesia providers, surgeons and other staff to discuss all aspects of safe care. “The posters state what needs to be checked off and what needs to be stated during the time out, including the correct surgery site,” says Mr. Bowers.

Use traditional patient identifiers such as birthdays and medical chart numbers in addition to confirming their name. “We’ve had two patients with the same names having surgery at the same time,” says Ms. Yost. “We want to make sure we have the correct Anna Smith who’s here to get Procedure X, not the one who’s scheduled to get Procedure Y.”

Surgeons typically lead time outs. That doesn’t change the fact that nurse circulators are the patient advocates who are in the room to ensure that the time outs are being performed correctly. Circulators should also make sure the entire team is involved, says Ms. Yost. If an anesthesiologist is reading off the patient’s name, the circulator should look at the patient’s ID bracelet and say, “Confirmed.”

It’s the circulator’s job to make sure everyone in the room verbally confirms all the components on the pre-surgical checklist and agrees with what’s going on. If that’s not happening during a time out, the circulator should address team members by name and ask if they agree that what was just stated was correct. The time outs are designed to orient everyone, not just the surgeon, to the incision site. A radiology tech, for example, also needs the double-check to confirm they’re using the C-arm to capture images on the correct side of the patient.

• Vet the process. Grading time outs should be part of monthly performance audits. If every aspect of the time out wasn’t discussed during an audit, members of the surgical team fail the audit. Track the results of audits and record which team members were involved. Look for trends, both positive and negative. The audits act as a deterrent to skipping time outs on the front end, says Mr. Bowers.

Fear of a bad audit score shouldn’t be the staff’s sole motivation, however. Recognize top-performing OR team members at staff meetings with verbal recognition, some sort of award such as congratulatory coins or ribbons, and reward them with meal tickets or gift cards to a local coffee shop, says Ms. Yost.

• Check pre-op images. X-rays, CT scans and MRIs can assist in helping to ensure you’re about to perform the surgery in the right place. “Images taken before surgery of whatever body part you’re operating on need to be pulled up in the OR,” says Mr. Bowers. “Because things can get confusing once a patient is put onto their side or otherwise moved, it’s important to not only have all imaging available, but ensure it’s displayed so everyone can see it.”