Executive Summary
Wrong-site surgery errors continue to happen at an unacceptable rate, along with retained foreign objects. Hospitals must look for new strategies to avoid these errors.
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Clinicians should be reminded that site marking is not foolproof.
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Having X-rays posted in the OR can help avoid laterality errors.
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A postop debrief can help avoid retained objects.
Wrong-site surgery errors persist even after years of concerted efforts to avoid them, and some of the standard prevention policies and procedures might not be effective enough. Some hospitals are finding other ways to prevent this never event and other errors.
Wrong-site errors occur in about one in 100,000 surgeries, according to a recent study. Also, surgeons leave a sponge or other item in the patient’s body in one out of every 10,000 procedures. (See the story in this issue for more information on that research.)
The researchers found that poor communication among medical staff was the root cause of many wrong-site and retained object errors. Another study, however, found that surgeons respond well and correct their behavior when told stories of how other physicians made wrong-site errors. (For more information on that research, see the story in this issue.)
The medical community has relied largely on the Universal Protocol, including time-outs before surgery starts to confirm the procedure, to avoid wrong-site errors. Those strategies are being augmented as more weak points are identified in the entire surgical process, says Coleen A. Smith, RN, MBA, CPHQ, director of high reliability initiatives with the Joint Commission Center for Transforming Healthcare in Oakbrook Terrace, IL.
For example, the Joint Commission Center for Transforming Healthcare recently began empha-sizing the registration step for surgery as a potential weakness in preventing wrong-site procedures.
“That was conspicuously absent in the Universal Protocol,” Smith says. “When we asked why the Universal Protocol wasn’t working as well as we wanted, we realized we had left a big portion of the process out.”
Orthopedic cases dominate the voluntary reports of wrong-site errors, Smith says. Wrong-digit or wrong-side errors are among the most common, along with spinal surgery at the wrong level.
Hospital risk managers also are finding other ways that can help. One hospital in California has found that having immediate access to X-ray images can reduce the incidence of this error. Surgical teams at Saddleback Memorial Medical Center in Laguna Hills, CA, routinely have the patient’s X-ray images available in the OR so they can confirm laterality before proceeding, explains Lead Clinical Risk Manager Danielle Gleason Tarricone, RN, JD, CPHRM.
“A few area hospitals had laterality issues with kidney removals, so based on lessons learned from those hospitals, we now require that images be posted in the OR and confirmed as part of our time-out process,” she says. “It’s an additional check to the site being marked.”
Saddleback Memorial has not experienced any wrong-site surgeries involving laterality, and Tarricone says she attributes that success partly to the X-ray policy. She notes that marking the operative site has been widely adopted specifically to avoid wrong-site errors, yet the strategy is not foolproof.
Now that clinicians have been trained to look for that site marking, they also have to be reminded that it might be wrong, she says.
“We heard through the rumor mill that in those local cases, the wrong side was marked from the get-go. The physician put in the wrong consent order, said left, marked left, but then when they pulled the film, it was right,” she says. “We felt that having the X-ray posted would help us catch the problem even if the wrong site was marked on the patient. It’s another safeguard against human error.”
Regional blocks also pose a risk for laterality errors, Tarricone notes, because the anesthesia provider relies on the surgeon’s site marking. Saddleback Memorial is implementing a new policy that requires the anesthesia provider to mark the correct site, in addition to the surgeon’s mark.
“Often these two marks will be very close together, but it’s another verification,” she says. “Two people are talking to the patient about where the procedure is going to be, and two people are marking it, so that’s another layer of confirmation.”
For the past year, surgical teams at Saddleback Memorial also have used an “end-of-case debrief” to reduce the incidence of retained objects, Tarricone notes. This new policy came about when OR nurses explained that it was impractical to count every single item used in surgery because there are so many. A single tray for one part of a procedure might contain dozens of pieces, and only a few might be used, for example. Many trays can be used in a procedure.
Tarricone confirmed that counting every item is not standard procedure even when a hospital requires counting, so she and her colleagues devised the end-of-case debrief to help account for the items not usually counted.
One question asked during the debrief is, “Is everything in the surgical field accounted for in its entirety?”
“It’s one of the last steps before the patient leaves the OR,” Tarricone says. “The patient might already be closed, but it’s a last check to make sure everything that should be out of the patient is accounted for.”
If the count is off or the end-of-case debrief raises concerns, all OR staff members are empowered to demand an X-ray before the patient leaves the OR. When a postoperative X-ray is ordered, the radiologist is notified of what item is unaccounted for and what it looks like, to speed recognition, Tarricone notes. “If for any reason the surgeon is refusing to put that order in, the staff member goes quickly up the chain of command and gets that X-ray performed before the patient leaves the OR,” she says.
Physicians did not eagerly embrace the end-of-case debrief, Tarricone notes. Time is money in the OR, and surgeons always have somewhere else to be, so they want out of the room as soon as their work is done. That desire makes them reluctant to accept a policy that requires them to stay in the OR even a few minutes longer, she explains.
Physicians who do not participate in the end-of-case debrief are reported to the medical staff for a behavior issue, she says. Smith also notes that hospital culture remains one of the biggest challenges in preventing never events. Staff members sometimes report that their efforts to conduct a time-out or properly mark the patient are rebuffed by surgeons, she says.
“We still think that there are situations where there are hierarchy and intimidation issues,” Smith says. “That’s where organizations are still struggling. It’s one of the hardest things to get right.”
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Danielle Gleason Tarricone, RN, JD, CPHRM, Lead Clinical Risk Manager, Saddleback Memorial Medical Center, Laguna Hills, CA. Telephone: (949) 452-7417. Email: [email protected].
