Wrong site surgery

Specialties Operating Room

Published

Hi all,

I know this is a sensitive subject and that we are all doing the "time-out", surgical site marking and everything that we can do to make sure things are done appropriately. But as we all know, mistakes still happen. My question for you all is this. Who, in your opinion, is responsible when there is a wrong site surgery? It has happened 3 times since I have been in the OR and each time the scrub tech and RN have both been suspended but absolutely nothing happens to the surgeon. I would like to know what you all have to say.

Thanks,

TJ

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Hi all,

I know this is a sensitive subject and that we are all doing the "time-out", surgical site marking and everything that we can do to make sure things are done appropriately. But as we all know, mistakes still happen. My question for you all is this. Who, in your opinion, is responsible when there is a wrong site surgery? It has happened 3 times since I have been in the OR and each time the scrub tech and RN have both been suspended but absolutely nothing happens to the surgeon. I would like to know what you all have to say.

Thanks,

TJ

Ultimately, the whole OR team is responsible and ALL should be disciplined and not one person left out. The purpose of the TIME OUT is to ensure the correct: patient, site, surgery, etc. If all of these are done EACH and EVERY time there should not be any errors. If the TIME OUT is not done or delayed, then that leaves room for error. The whole OR team is there to act as the patient's advocate when they are rendered unconscious, therefore, the ONUS is on ALL. I have done my TIME OUT for 10+ diligently and had no errors. You should be speaking with your director or upper administration as to why the 'others' were not suspended or disciplined. Good luck with your quest!

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Where was anesthesia during this time? They are also part of the team?

If I remember correctly, you are a fairly new OR nurse, and if you have already seen this three times at your facility, I would consider looking for another venue.

Was the staff actively participating during the time out period? If so, all are held accountable, and this means everyone. Did they actually have a time out period?

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This post is amazing, in 20 years I have had problems with wrong side consent forms which we have caught in the pt assessment phase of the OR reception but never never never have we actually operated on the wrong side. What are the unit staff doing, what are all the OR nurses checking when assessing the patient, what are the surgeons doing, are you all asleep there. I am sorry I sound so harsh, one wrong side and I believe we all are capable of mistakes, but 3!!!!!!!!!!!!!!!!!!!!!!. I think if the same teams of surgeons and OR nurses are involved they should be kicked out for stupidity and incompetence and if you are not part of this team, get far away from them, 3 times, the mind boggles here in London!!!!!!!!!!

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Specializes in 5 yrs OR, ASU Pre-Op 2 yr. ER.
It has happened 3 times since I have been in the OR and each time the scrub tech and RN have both been suspended but absolutely nothing happens to the surgeon.

I think outrageous that those were the only two disciplined.

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During my period in the OR I never had a bad outcome regarding operative sites. During my periOperative course we were taught the surgeon is responsible for identifying the operative site. This was a sticking point with some surgeons and myself because they would not mark the site. If I could not get the physician to mark the site then I would ask the patient to mark the site. Everyone I asked, smiled. Many added, at least I know he will cut the right one.

Within months of finishing the periOperative training, the hospital came up with a policy regarding operative site identification. We were told it was taken from a statute (state specific I am sure). The policy designated the physician as the medical person to mark the operative site with a permanent marker. Even with the policy there were many resistant surgeons.

If the proper procedures are utilized then a wrong site operation should not occur. Of course, you have to have the right patient. You must confirm with the patient what the operative procedure will be including site. The consent must be consistent with the patient's understanding of the operative procedure. The surgeon confirms with the patient what operation is going to be done. This is all done prior to any medication. Once the patient gets into the operating room, the circulating nurse and scrub tech/nurse must confirm with the doctor and anesthesia the operative procedure including site. Where I worked there was an Expo Board for sponge counts etc. The operative procedure was also listed on this board.

You incident is the exact reason why this area was a sticking point for me with surgeons. I had heard case law before where the surgeon and anesthesia were not assigned any blame. As one who does not want to put my nursing license at risk, I took a firm position regarding the surgeon identifying the surgery site. I tried to be present when the surgeon saw the patient to witness the confirmation between surgeon and patient but this was not always possible. This position will put you at odds with some surgeons so maybe someone else has better ideas.

Do you have a periOperative nursing book? This is imperative because you are responsible for your nursing actions.

Good Luck!

Hi all,

I know this is a sensitive subject and that we are all doing the "time-out", surgical site marking and everything that we can do to make sure things are done appropriately. But as we all know, mistakes still happen. My question for you all is this. Who, in your opinion, is responsible when there is a wrong site surgery? It has happened 3 times since I have been in the OR and each time the scrub tech and RN have both been suspended but absolutely nothing happens to the surgeon. I would like to know what you all have to say.

Thanks,

TJ

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I have been in the OR for six years and have never heard of time out. What is it?

We were doing an arthroscopy on a young gentleman....depending on the surgeon either he/she or the nurse marks the limb after asking the pt which we are doing. We got the pt back to the or, anesthetized, and as I was scrubbing the leg, I noticed a nasty infection on pts toe. I reported this to the surgeon....he replied "good job" but someone should have spotted this before he got back to the OR. ie: The nurse shaving the leg preop, the circulating nurse marking the leg, anesthesia pre op...SOMEONE! Fortunately it was caught before surgery at least or pt could have ended up with a nasty infection.

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Specializes in NICU.

When I was in nursing school, I spent a little time in same-day surgery. One of my patients was a surgeon himself who needed knee arthroscopy. Before coming in that day, he had taken black permanent marker and written on his good knee - "NOT THIS KNEE FOR SURGERY!"

I asked him if he expected there to be a problem. He said, no, but that it does happen from time to time. He said he figured if he made it obvious when side needed surgery, he'd be fine. Honstly, if I even need surgery, I'm taking a page out of this guy's book.

I also think it's very unfair that the nurse and tech were the only ones disciplined in the case above!!!! If anything, it should be the doctor that responsibility falls on. Makes me so mad to read that!

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Back in the early 90s, a surgeon operated twice on the wrong extremity. If I recall correctly, one included an amputation of the wrong leg. It wasn't until after his second mistake that he was suspended, for a period of time. He came back and was suppose to operate only under supervision. He didn't and I believe he lost his license. He made his first two 'errors' at University Hospital, Tampa. Perhaps someone else recalls the facts. I think that everyone is responsible but generally the surgeons do not get discplined.

Grannynurse :balloons:

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