Wrong site surgery - how to prevent

SkipBeat · Jul 13, 2011

Timeout, Surgeon marks site before pt is in OR, and pt verbalizes correct site.

SnowStar4 · Jul 13, 2011

Timeout, Surgeon marks site before pt is in OR, and pt verbalizes correct site.

Same here.

Editorial Team / Admin · Jul 13, 2011

Same here.

I third that- surgeon has to mark (not anyone else), patient confirms type of surgery and location before entering OR, timeout with anesthesia before patient asleep, timeout with surgeon before incision.

NurseSnarky · Jul 15, 2011

I third that- surgeon has to mark (not anyone else), patient confirms type of surgery and location before entering OR, timeout with anesthesia before patient asleep, timeout with surgeon before incision.

Yes to all but timeout with anesthesia...that would be a good one to add. Might try that tomorrow. It's not policy to T/O with anesthesia.

I got a doctor hoppin' mad the other day because it was a case on one side of the face...an eye maybe? Anyway I hadn't worked with him yet and I noticed in pre-op the patient wasn't marked, but had talked with the doc. I found doc in the hall and asked him if he had planned to mark, "no I don't". As I'm handing him a marking pen, I say, "well at least you're honest. Now please mark the patient, even a dot to show we're all on the same page". He grabs it out of my hand while trying to read my name tag and puts a dot on the patient's face at the surgical site all the while saying, "well I guess I HAVE to mark you first". Then he stomped off. Uh yea, ya do. The rest of the cases that day, they were marked ahead of time. We have a few that don't want to do anything they don't want to. At least two don't want to hear the timeout..."there are much more important things". I do it anyway...it's MY JOB and PATIENT SAFETY. So then I've not been in one doc's room for six months! We get along fine outside of his cases...he just wants his own way and I do what p&p state and what I'm supposed to do.

SandraCVRN · Jul 15, 2011

All of the above AND we recently changed to the SURGEON initiating the timeout. Consent open, full blown everyone involved. If the surgeon balks they get talked to by surgery exec committe, then they behave:yeah:

There are still a couple times when we all can forget but it has worked out very well. Marking that can be seen after prep is also a BIGGIE.

lockheart678 · Jul 15, 2011

The doctor marks the surgical site and initials it, we have the patient verify and match it up with the consent form, and during our timeout, everyone participates. It's usually not a problem, but sometimes my anesthesia doesn't know when to shut up. The surgeons are always on them when they continue to ignore me as I try to get their attention. Whenever a surgeon has images up, they'll also want the patient's medical record read off and they match it to the images as well.

Argo · Jul 15, 2011

H&p updated and on the chart, consent signed by everyone and on the chart, surgery orders signed and on the chart- all matching. Sight market by surgeon, timeout with consent out and verified by second party, either held up for surgeon to see or Anesthesia confirms....

ORNurse1 · Jul 16, 2011

Currently we started the WHO version of patient safety checklist. There is a preop portion which includes: h&p, consent, marking, labs, blood products, images, antibiotics, DVT prophalaxis, and implants. Then there is an anesthesia checklist: airway difficulty, blood loss, any special concerns or equipment. Then time out portion prior to incision: patient idenity, personnel present, surgery, site, antibiotics, blood, products, equipment, length of surgery, special concerns, sterile indicators present and indicative ofmsterilization process. Then at the end of surgery we have a sign out: post op diagnosis, procedure, specimens, equipment concerns, SBAR.

At first we all had a hard time with it because it contains a lot of different information at various times but you end up doing all those things we are just now documenting that we are doing them.

4_Sq · Jul 16, 2011

The WHO guidelines have caused a major kerfuffle in our OR.. there is animosity between surgeons, anesthetists, nurses etc.. over how the time out is to be "conducted"

Time Out is very important, and, if it prevents wrong site surgery, this is the KEY, but sometimes I think it detracts from the task @ hand and actually poses more of a risk to the patient when people are conflicting over how it is to be performed..

Does anyone out there have complete compliance in performing the time out, and is it done in a manner that it is including the Surgeon, Patient, Nurse, & Anesthetist?

Please show me how!!

GadgetRN71, ASN, RN · Jul 16, 2011

The WHO guidelines have caused a major kerfuffle in our OR.. there is animosity between surgeons, anesthetists, nurses etc.. over how the time out is to be "conducted"
Time Out is very important, and, if it prevents wrong site surgery, this is the KEY, but sometimes I think it detracts from the task @ hand and actually poses more of a risk to the patient when people are conflicting over how it is to be performed..
Does anyone out there have complete compliance in performing the time out, and is it done in a manner that it is including the Surgeon, Patient, Nurse, & Anesthetist?
Please show me how!!

One of the places I worked did it this way, which I think was pretty good.

In holding, the surgeon marks the patient and a sign out is conducted with the holding nurse and the anesthesia provider.

In the room, the attending, the circulator and the anesthesiologist ID the patient, using the consent, the armband and the blue card. They had a paper that had to be signed after this was done. The patient was still awake at this point so they could chime in too, if there was a discrepancy.

Once the case was ready to be started, the surgeon would initiate the time out, stating the patient name, the procedure with any applicable laterality, and the mark. At this time, the circulator has the consent out and visible. The surgeon would then ask if everyone could see the mark. People would have to state out loud, "I see the mark". The anesthesia person stated the patient name and any antibiotics. The circulator stated the patient name and the procedure with laterality if applicable. The surgeon then asked "are there any concerns?". If no, then surgery could proceed.

At the point of the time out, everyone was to be paying attention, music was to be off. This whole process was not negotiable either, if any physician balked, the consequences would not be good. IMO, it needs to be this way. It might seem stupid to have to be this stringent, but these mistakes happen daily around the country. I knew surgeons and staff who were involved in wrong site surgeries, and these were good practitioners. I think the people who swear up and down that it'll never happen to them so they don't need all the rules, are actually the dangerous ones. Thank god, I've never been involved in one. Watching the staff go through these things has made me a stickler for policy and an intense patient advocate.

I look at it like this..I can afford to have a surgeon mad at me, or a hospital administrator.(patient safety often comes second to the almighty dollar). I can find another job. But, if the Board of Nursing is mad at you, you are in a bad way. It's a lot easier to go after the staff in the room rather than the surgeon.

4_Sq · Jul 17, 2011

Thank you very much gadgetRN71, great suggestions, this sounds like the "Perfect" way prevent wrong site surgery.:paw::paw::paw::paw: