João Pedro Ribeiro
Despite many years of campaigns by major organizations to prevent this kind of event, wrong-site surgery (which includes wrong procedure, wrong patient, wrong side and wrong site) is an all too common mistake. Wrong-site surgery is generally caused by a lack of a formal system to verify the site of surgery or a breakdown of the system that verifies it. The top root causes of wrong-site surgery are communication failure, procedural noncompliance and lack of engagement from senior leadership.
The adverse event still occurs approximately 40 times a week in the U.S. only. It seems also relevant to note that in 1998, the American Academy of Orthopedic Surgeons (AAOS) reported that orthopedic surgeons had a 25% chance of performing a wrong-site surgery during their career. Such experience can have a negative impact on the surgeon and the surgical team and be devastating for the patient. Here are five ways hospitals and ambulatory surgery centers can prevent-wrong site surgery.
1. Implement a checklist. The literature shows that the implementation of such protocols has improved patient safety by decreasing post-operative complications and mortality. In addition to improving patient safety, an important goal of using surgical safety checklists, like the World Health Organization’s, is to help preventing human error that may result in wrong-sided surgery. The use of a checklist identifies everything that needs to be done preoperatively, including marking the side and site of the surgery. Generally, the operating room circulating nurse is in charge of the checklist, though the surgeon or lead provider is responsible for marking the site and side of surgery. Since operating rooms can, naturally, be noisy and distracting environments, some organizations enlarge the poster and attach it to the wall so that every provider can watch the circulating nurse check off the essential steps. Site marking is, actually, part of the Joint Commission’s Universal Protocol requirement, developed in 2004. The Universal Protocol includes preoperative verification of the patient and the site, surgical site marking, and a time-out before any planned surgical procedure. The Joint Commission made the Universal Protocol mandatory for all accredited institutions within its oversight.
2. Watch for miscommunication during hand-offs. One way that these checklists improve patient safety is through their effect on team communication. The concept of the surgical time-out, a planned pause before beginning the procedure in order to review important aspects with all involved personnel, was developed to improve communication in the operating room. The Universal Protocol also specifies the use of a time-out prior to all procedures. Although initially designed for operating room procedures, timeouts are now required before any invasive procedure. So it becomes critical to perform a preoperative briefing upon arrival in the operating room.
3. Think outside the operating room. Some facilities concentrate their wrong-site prevention efforts on the operating room and forget about other areas of the hospital. There are chest tubes and surgical procedures that are done in the intensive care unit, emergency room and other departments who think they don’t have to abide by wrong-site surgery protocols. Organizations should encourage prevention efforts throughout the facility, taking time to emphasize that departments where surgery does not traditionally occur are not exempt.
4. Involve everyone – patient included. Some providers may be hesitant to implement a time-out or a checklist because they feel immune to errors. Every team member shall be involved though. The best protocol involves the patient as well, and would be to require the surgeon to mark out the surgical incision while the patient is still in the holding area. Providers should talk to the patients and involve them in marking the site and side of surgery. This might mean saying, “Mr. Doe, we’ll be operating on your right knee today. Is that correct?”, or asking an open question like “Which knee am I operating today?”, depending on the patient’s level of education and cognition.
5. Keep the surgical instruments in the back of the room until completion of the time-out. This practice helps avoiding that team members are distracted, feeling rushed or worried with setting up equipment during time-out.
In conclusion, teamwork, communication, engagement and preparation are, without any doubt, critical factors for success, thus reducing the probabilities of errors.