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Cut It Out: AORN urges OR nurses to speak up to prevent wrong site surgeries

OR Today | Cover Story | Cut it Out

In our imperfect world, mistakes happen, including in the OR. But few OR mistakes are as potentially costly as wrong site surgeries—in terms of needless patient pain and suffering (and even death), of course, but also financial loss and damaged reputations to hospitals, surgeons and OR staff members.

Although wrong site surgery has been an enduring subject of protocol and process improvements since The Joint Commission declared it a sentinel event in 1998, it remains a serious and preventable threat to patients in the OR that should never happen. According to The Joint Commission Center for Transforming Healthcare, some estimates put the national incidence rate— which includes wrong patient, wrong procedure, wrong site and wrong side surgeries—as high as 40 per week.

The Joint Commission reports that “wrong-patient, wrong-site and wrong-procedures” was the second most frequently reported sentinel event last year. It reviewed 819 such incidences between 2004 and 2011, including 152 last year. However, many experts believe the actual numbers are as much as 10 times higher than this, since reporting is not mandatory in most states.

“The Worst Feeling of my Life”

One of the most publicized of these cases occurred at Massachusetts General Hospital a couple of years ago, when a surgeon made a very public admission and apology for performing the wrong procedure on a patient. The surgeon explained in detail how, through a series of missteps (including failure to perform a surgery time out) and in less-than-ideal circumstances (including a language barrier with the patient), he performed a carpal tunnel release on a patient, instead of the trigger-finger release he should have performed.

“It was the worst feeling of my life—the ground literally falls beneath you,” the surgeon commented in an interview afterward. Fortunately, the patient suffered minimal ill effects and did not file a lawsuit; rather, she received a modest compensation from the hospital, which installed safety monitors in its ORs afterward.

But not all wrong site surgery cases end this painlessly. A children’s hospital in Arkansas was hit with a $20 million negligence verdict for performing a surgery on the wrong side of a 15-year-old boy’s brain and then not disclosing the error to his parents for more than a year. The boy was left psychotic and severely brain damaged.

On the financial side, the average payment made by hospitals to patients who are subjected to wrong-site surgeries is about $81,000 in cases resulting in a lawsuit, and about $47,000 in cases resolved outside the court, according to research conducted by Philip F. Stahel, the director of orthopedic surgery at Denver Health Medical Center. According to the American Academy of Orthopaedic Surgeons, orthopedists have a 25 percent chance of making a wrong site error at some point in their careers.

Types of Wrong Site Surgeries

Wrong site surgeries run the gamut, from amputating the wrong limb to performing the wrong procedure or performing a procedure on the wrong patient. Along with retained surgical items, they remain one of the Joint Commission’s most frequently reviewed “never events.”

“We know that wrong site surgery should never happen, but the problem persists,” states Joint Commission President Dr. Mark Chassin. While stressing that wrong site surgery is rare, Chassin acknowledges that “when it does happen, it is a devastating event that is often life-altering for the patient who experiences it.”

Diane Pinakiewicz, the president of the National Patient Safety Foundation, concurs with Chassin: “Despite concerted efforts by The Joint Commission and other national patient safety organizations, we still have not been able to get wrong site surgeries under control.” In particular, The Joint Commission’s Universal Protocol is a standardized approach to eliminating wrong site surgery that includes pre-procedure verification, site marking and a surgery “time out.”

The surgery time out confirms the surgical site, patient and procedure. “It is the time when the entire surgical team pauses to confirm and agree that the ed Solutions Tool. Using the Tool, take shortcuts, make mistakes, appropriate surgery is about to be the group reduced their number fail to support others, demon performed,” explains Linda Groah, the executive director and CEO of the Association of periOperative Registered Nurses (AORN). “An effective and well-executed time out is an important part of what should be a multi-layered defense against wrong-site surgery.”

The surgery time out is similar in some ways to the prescribed checklist that pilots and co-pilots are required to complete without interruption before a commercial airliner can take off. But unlike in the aviation industry, surgeons and OR staff are not legally required to perform the surgery time out.

The Joint Commission’s most recent effort to prevent wrong site surgery was unveiled earlier this year by its Center for Transforming Healthcare: a Targeted Solutions Tool that’s designed specifically to help hospitals prevent incidences of wrong site surgery. The Tool enables hospitals to evaluate risks across their entire surgical system—including scheduling, pre-operative and operating room areas—so they can determine the root causes of wrong site surgeries and develop specialized strategies to address them. It also helps hospitals monitor their surgical cases for weaknesses that might result in a wrong site surgery.

Twenty-nine potential causes of wrong site surgery were identified by the group of eight hospitals and ambulatory surgery centers that worked with the Center in developing the Target of surgical cases with risks by 46 percent in the scheduling area, 63 percent in pre-op and 51 percent in the operating room.

“The Targeted Solutions Tool offers organizations a straight forward approach to identifying and eliminating risks of wrong site surgery in all phases of the process of surgery, from scheduling to the operating room,” says Dr. Chassin.

How Wrong Site Surgeries Occur

The potential causes of wrong site surgery are many: miscommunication about a patient’s left or right side, mixing up patients’ test results, and incorrect markings on a patient (or no markings at all) are a few of the most common. Dr. Chassin believes that growing time pressure on surgeons is also a large contributing factor.

Groah points out an even more common cause: “Poor communication is frequently found to be the fundamental cause of many issues that result in wrong site surgery,” she says. In a study titled “The Silent Treatment,” which was conducted by AORN, VitalSmarts and the American Association of Critical Care Nurses (AACN), poor communication was revealed to be the culprit behind the majority of OR mistakes, including wrong site surgery.

More than half of the nurses, physicians, clinical-care staff and administrators who responded to the survey said they had witnessed coworkers break rules, strate incompetence, show poor teamwork and clinical judgment and act disrespectfully. However, less than 10 percent directly confronted their colleagues about their concerns.

“Creating a culture where OR staff is not afraid to speak up before problems occur is a vital part of the solution to wrong site surgery,” Groah says. “But this has to come from the top down— there has to be an upper management philosophy of support for staff members who speak up.”

AORN’s comprehensive surgical checklist includes specific steps to be followed at four key surgical phases: pre-procedure check-in, sign-in, timeout and sign-out. “The surgical checklist includes processes that have been learned in other industries and applied to the OR in order to minimize the chances of mistakes like wrong site surgery,” says Pinakiewicz. Download the comprehensive surgical checklist at

“Team dynamics and policies and procedures, including the comprehensive surgical checklist, are critical to helping prevent wrong site surgeries,” Pinakiewicz says. “The OR nurse must insist that they be followed, and all OR team members must feel empowered to speak up if they feel that something isn’t right.”



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