6 tips to avoid wrong-site surgery
6 tips to avoid wrong-site surgery
A patient needed repair of a right hip fracture. The site was marked by the patient, and the OR team performed a surgical pause. However, the patient’s left hip was draped and prepped, and the surgery proceeded on that side. After the incision had been made, the error was realized. The incision was sutured, the patient was repositioned, and the surgery resumed on the right side.1
This actual event reported in Pennsylvania is not rare. An analysis of the first 500 wrong-site surgery events reported to the Pennsylvania Patient Safety Authority between July 2004 and August 2012 found that physicians initiated an intended procedure at an incorrect site on the correct patient in 433 (86.6%) of the 500 event reports. The authority recently released its analysis.
The report makes these recommendations:
• Preoperative documentation of the site of surgery should be specific enough for all OR team members to anticipate the correct location of the mark.
Staff members might not designate the side on the paperwork, or they might designate a general location, such as lumbar spine or cervical spine, without noting the particular disc involved, says John R. Clarke, MD, editor of the Pennsylvania Patient Safety Advisory and clinical director of the Pennsylvania Patient Safety Authority, both in Harrisburg, and professor of surgery at Drexel University, Philadelphia.
This problem is particularly prevalent with surgery involving fingers and toes, because the staff might not note which part of the finger or toe is being operated on, Clarke says. With fingers, “there are three sections, so there is the opportunity to get into the wrong part, even though it’s on the right finger,” he says.
• Having the patient state two identifiers to verify their identity appears to be effective in preventing wrong-patient errors.
Patient identification often is not done properly, Clarke says. For example, a staff person may say, “Mrs. Jones?” and the patient replies “yes.” “They assume that is the correct identifier,” Clarke says.
Staff should ask patients so they receive an “active voice response,” he says. Instead of asking, “Are you Mrs. Jones?” the staff person should ask, “What is your name?”
There was a near miss in Pennsylvania in which the only difference between a patient in the computer system and patient showing up for surgery was the middle initial and the month of birth, so the date of the month and year of birth, as well as the first and last names, were the same. The preop nurses caught the difference by checking the patient’s wristband, Clarke says.
• Marks should be made as close to the intended incisions as possible. The exact location of skin and subcutaneous lesions should be marked.
With surgery on fingers and toes, for example, don’t put an arrow pointing to the correct appendage, Clarke warns. “People might say it’s pointing to the first or second toe,” he says. Instead, the mark should be exactly where the incision will be made, he says.
With surgery on skin lesions, a patient might have multiple moles or bumps/lesions. You should have a mark around the exact lesion that’s being removed, Clarke says.
• The most likely wrong-site error, by far, is a wrong-side error. Bilateral structures, especially extremities and eyes, are most likely to experience wrong-side surgery. The most common wrong-side error is the anesthetic block, accounting for 34% of all wrong-side errors and 21% of all wrong-site errors in the OR area.
About one in five persons becomes confused over his/her right and left, Clarke says. That confusion is magnified when looking at a different person, he says. Additionally, patients may be turned over, so the left and right sides are reversed, Clark says.
• Some wrong procedures may result from surgeons becoming distracted during the operation. The OR team should maintain situational awareness of the intended procedures throughout the case, not just at the start of the case.
One typical example is bilateral ear tubes and adenoidectomy. “Most of time when an ENT surgeon is operating on a child, it’s a tonsillectomy, so the automatic thinking is to immediately go for the tonsils,” Clarke says. Another typical area of confusion is a hysterectomy, because a surgeon is accustomed to taking out the ovaries at the same time.
Often the scrub tech is the one who notices the mistake, based on the surgeon’s request for equipment, and reminds the physician this case is different. “Sometimes surgeons are inherently taciturn,” Clarke says.
• Wrong-level spinal procedures represent 13% of all wrong-site procedures. Intraoperative misperceptions were reported nine times as often as errors based on misunderstandings of information available preoperatively. The prevention of wrong-level spinal procedures requires intraoperative verification of the correct spinal level.
Almost all surgeons are doing some form of intraoperative verification with fluoroscopy or X-ray, Clarke says. Mistakes can happen when a surgeon marks a vertebra, for example, and the X-ray shows that mark is one vertebra too high. Rather than mark the correct vertebra, the surgeons often say, “I’ll just go one further away,” but they mistakenly can go two vertebrae away, Clarke says.
Physician compliance is one of the biggest hurdles for wrong-site surgery, he says. Anesthesia blocks are among the biggest problems. Physicians are trying to be as efficient as possible, Clarke points out. “They’re not really stopping and taking the time to go through all the steps in an optimal fashion, he says. “They need to slow down.”
Wrong–site surgery is like wearing seatbelts in that some physicians can’t be bothered with the prevention, and adherence comes only from a bad experience, he says. That lack of adherence is unfortunate, Clarke says. “It’s not that to numb the wrong part of the body is necessarily the worst bad outcome you can have happen, but it’s not something you can easily excuse.
Reference
1. Clarke JR. Quarterly update: What body parts and procedures are associated with wrong-site surgery? Pennsylvania Patient Safety Advisory 2013; 10(1):34-41. Web: http://bit.ly/17G1GUR.
Resource
• The Pennsylvania Patient Safety Authority has educational tools to prevent wrong-site surgery. Go to web: http://bit.ly/nTXLxH.
A patient needed repair of a right hip fracture. The site was marked by the patient, and the OR team performed a surgical pause. However, the patients left hip was draped and prepped, and the surgery proceeded on that side. After the incision had been made, the error was realized. The incision was sutured, the patient was repositioned, and the surgery resumed on the right side.Subscribe Now for Access
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