Preventing wrong site surgery: X marks the spot


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    Specializes in Vents, Telemetry, Home Care, Home infusion. Has 46 years experience.

X" Marks the Spot

Going in for surgery and receiving the procedure you were expecting seems like it should be a no-brainer, but recent studies suggest an alarming rate of wrong-site, wrong-procedure and even wrong-person surgeries at U.S. hospitals.

There are no good excuses for surgical errors, at least not according to the Joint Commission on Accreditation of Healthcare Organizations, which has issued its second Sentinel Event Alert trying to call attention to wrong-site surgery. A second such warning sent to the organization's 18,000 accredited hospitals is rare, and it indicates the current severity of the problem in U.S. hospitals.

At the time of the first alert in 1998, 15 cases of wrong-site, wrong-person or wrong-procedure surgery had been reported to the JCAHO. By the end of 2001, the database had swelled to 150 cases. The JCAHO says that figure doesn't even begin to tell the story.

"We only know about surgical errors through what hospitals, patients and families, or newspapers report," says Richard Croteau, M.D., executive director for strategic initiatives at the JCAHO. "By those methods, we only capture around 5 to 10 percent of what is actually happening."

Croteau says existing data on wrongful surgeries is hard to analyze at best. "It's really hard to say whether actual incidence is going up or down," he says. "The fact is, we've continued to receive reports of wrong-site surgery cases since the original Sentinel Event Alert. It suggests there's been little or no improvement."

Of the cases reported to the JCAHO, 76 percent involved surgery on the wrong body part or site, 13 percent involved the wrong patient and 11 percent involved the wrong procedure.

Communication breakdowns between surgical team members and the patient and family were attributed as possible root causes of the alarming statistics, JCAHO data suggests. Other contributing causes included a failure to require clear marking of the surgical site, failure to verify the procedure in the operating room, and incomplete patient assessments.

Croteau says that surgeons often are resistant to the one thing believed to have the greatest effect on reducing errors-marking the surgical site. They feel that an accident can't happen to them, or that marking the site would make the patient lose confidence in them, he says. "But when we talked to patients, we didn't get that kind of report. Patients liked the idea of marking the site and doing anything that would reduce the risk of any misadventure."

The New York State Health Department has recommended that healthcare facilities throughout the state develop policies for verifying the correct patient and site, and for marking the site prior to surgery. In Florida, the Board of Medicine went even further in June 2001, instituting penalties for wrong-site surgery. Physicians could be fined up to $10,000 and required to give a one-hour lecture to colleagues about the error.

Croteau says such a move could backfire. "If we keep punishing people, it's going to continue to drive it underground," he says. "You can't build policies that say 'Don't make mistakes.' When things go wrong, it's not just one person." He says systems need to be designed to prevent these errors.

VHA Inc., a nationwide network of community-owned healthcare organizations and hospitals, began a program aimed at preventing surgical errors in the spring of 2001. VHA says physicians at its 2,200 affiliated organizations perform more than 8.2 million surgical procedures annually-about 30 percent of the surgeries done in this country each year.

Known as the "Seven Absolutes," the VHA program sets seven minimum standards hospitals should consider in preventing surgical errors. "Our initial analogy was relating it to aviation and how there is such a need for a concise standard pattern each and every time one operates," says Remar Thorsness, R.N., director of nursing leadership for VHA.

During the past year, VHA has trained more than 2,600 physicians and nurses from 550 hospitals across the country. The program includes such measures as scheduling surgery with a "right or left" designation, if applicable. It also advocates marking the surgical site, but leaves the specifics up to each institution.

One of the VHA member hospitals, Integris Baptist Medical Center in Oklahoma City, Okla., chose to mark the surgical sites with tape, instead of indelible marker. "The tape was a recommendation from our surgeons because they did not want to have ink on the skin in the line of the incision," says Janet Lewis, R.N., administrative director of surgical services at the medical center. "That was the value I found of bringing this to a committee of physicians to have them sit down and work with nurses and come up with a consistent plan. Generally these kinds of policies are developed only with nurses."

Integris Baptist has trained more than 100 operating room staff, in addition to nurses in the surgical admissions area, on its wrong-site prevention policies. Lewis says she doesn't know how the error rate may have changed since the policy was implemented, but she had heard about some close calls. "There have been times at the last moment when the operating room team has asked, 'Is this right or left?' and people were not on the right track," she says. "The biggest thing is that it's heightened the awareness of everyone. We have documentation and we record each step."

The JCAHO, along with support from the American Academy of Orthopaedic Surgeons and the American College of Surgeons, recommends clearly marking the surgical site; creating a checklist for the surgical team to follow; orally verifying the type of surgery with each member of the surgical team; and running a final double check to make sure the team is in agreement as to the proper site of the surgery.

While checking the patient's name and procedure three or four times out loud might seem like overkill for operating room staff, experts say it's the least that everyone can do to prevent harm. "We've got to get past this myth of perfect performance by doctors and nurses," Croteau says. "If our goal is to eliminate medical errors, we're going to fail. But if our goal is to prevent patient harm, we've got a good chance of success."

-Beth Berk

What is YOUR facility doing???


51 Posts

I no longer work, but I recently had ankle surgery. The admitting nurse handed me a magic marker and had me write "yes" on the ankle having the procedure, and "no" on the other ankle. I personally feel that marking the site would prevent alot of mistakes----and it is a no brainer!!


1,961 Posts

My hospital does this also :D



1 Article; 2,334 Posts

Last November my 2 boys had knee surgery one day apart, opposite scheduled 4 mo in advance, one an emergency...imagine the confusion...same Nurse had both boys, she gave them a marker, had them write yes & no on the appropriate knee AND had them write I am (first name) on the yes knee.

I never thought of giving the marker to the patient. We'd heard stories of people having surgery on the wrong body part, and between us nurses, decided that marking things was a good idea. Of course, in neuro, we mostly saw people having or who had HAD back or cranial surgery.

It's probably a policy there now.

None of the patients ever got upset about marking on them. I guess we kind of made a game of it. I think it's even a better idea to have the patient do it (if it's not back surgery) because then nobody could accuse the nurse of MARKING the wrong site!



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