Wrong site surgeries are very rare, but sometimes wrong site surgeries happen. The wrong site surgeries have damaging results for the patient and pose a huge safety problems within the organization. Usually communication breakdown is considered the main cause of wrong site surgeries in the surgical team.
The Joint Commission’s universal protocol of “time out” is a very important and a helpful tool in preventing the wrong site surgeries, wrong person surgery, and wrong procedure. The factors causing the wrong site surgeries can be; • presumption of surgical team members that someone else has confirmed surgical site and procedure • surgeon failing to mark the site.
• placing the x-rays backward causing the laterality to reverse • Lack of communication between the surgeon and patient • In single encounter performing multiple procedures • Surgeries requiring patient to position in different angles on the OR bed • Failure of surgeon to include the patient and family members when identifying the correct site • Partial pre-operative assessment of the patient • Pressure to reduce the pre-operative preparation time The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has come up with the universal protocol, a very helpful tool in preventing wrong site surgeries.
The universal protocol includes pre-procedure verification of the surgical site by the surgeon and marking the site, verification of the correct site by the anesthesia provider and the circulating nurse with patient or family member in case of minor or mental retarded patients. The purpose of the pre-procedure verification is to identify the patient, the procedure, site, availability of required x-rays, instruments, and implants. Any missing information or discrepancies can be addressed before the patient could go to the operating room and save lot of time (Makary & Mukherjee, 2007).
As per JCAHO, the verification of the correct person, correct site, and correct procedure needs to occur while the patient is awake and aware at different times; • At the time the procedure is scheduled • At the time of pre-admission testing • At the time of admission for the procedure • Before the patient leaves the pre-operative holding area • Anytime the responsibility for care of the patient is transferred to another member of the procedural care team (JCAHO, 2003).
In my agency, the surgeon sees the patient in the clinic, verifies the diagnostic results of the tests with patient, determines the site of surgery with the patient, schedules the surgery with proper laterality, and makes a note on the patient’s chart with the history and physical findings, and writes correctly the surgical site. On the day of surgery the patient’s chart comes to the pre-operative holding unit with the patient’s signed consent and necessary radiographs (if the radiographs taken outside hospital).
The pre-operative holding unit nurse verifies with the patient, name, date of birth, procedure with laterality, updated history and physical for the day of surgery, site marked, and checks off the pre-operative checklist. The anesthesiologists verifies the patient with the name, date of birth, the procedure scheduled on the schedule, the procedure and laterality with the patient and the consent, marking of surgical site, and checks off the pre-op checklist.
The circulating nurse goes to the pre-operative holding area, meets the patient and family, checks the patient with name, date of birth, checks for day of surgery history and physical updates, checks for the surgical site marked, and verifies with the patient, schedule, and consent form, and checks off the pre-op checklist. In case of a minor or mentally incompetent patient verifies with the family. If any discrepancy alerts the surgeon.
Also the pre-operative holding area nurse makes sure that the patient will not receive any sedation or narcotic pain medication until all the team finish interviewing the patient and making sure everything is correct and matches with the procedure. As per AORN’s Correct Site Surgery Tool Kit, the site of surgery has to be marked prior to surgery and with the collaboration of patient and family by the person who is conducting the surgery. A blue band will be applied on the patient’s wrist and site of surgery will be written, in cases of surgery to conduct on mouth, lip, and eye.
During “Time Out” the circulating nurse will read the site on the wrist band and the team will agree prior to surgical incision (AORN, 2001). Once everyone finishes interviewing the patient, the anesthesiologists bring the patient to the operating room. In the room, the nurse again confirms, if she has received the right patient by checking the patient’s identification band and by asking the patient. Before prepping the surgical site, the nurse, anesthesiologist, and the surgeon confirms the patient, the surgical site, and position of the patient. The nurse does the surgical “Time Out,” once the patient is draped, and just before the incision.
During time out, the nurse will loudly announces the elements of time out; correct patient, verifying the correct site and laterality, correct position, correct procedure, availability of correct implants or equipments, availability of pre-op radiographs, any prophylaxis antibiotics, and allergies. Safety is a significant characteristic of the excellence of care in a multifaceted hospital setting like the Operating Room. Communication breakdowns have been reported to be the cause of 60% of sentinel events reported to the Joint Commission on Accreditation of Healthcare organizations (Atkins & Royle, 2007).
The facility has acquired a white board policy in every operating room to prevent harm to the patient through communication breakdown. There are three status checks to conduct before the surgery could commence. As soon as the room opens for surgery, any member of the surgical team will write on the whiteboard that day’s date, names of the staff in the room with roles, patient’s name, medical record number, and name of the surgery with laterality.
The circulating nurse makes sure that the team received the right patient in the room and checks the status check one, i.e. , right patient. Once the patient is positioned for surgery, again the circulating nurse again checks with team the surgical site and confirms with a check on the status check two on the whiteboard, and starts prepping the surgical site. Once the patient is covered with the sterile drapes and just before the surgical incision, again the circulating nurse confirms the surgical site by conducting a “Time Out” and checks on status check three on the whiteboard. This change in process helped the facility to bring down the occurrences of wrong site surgeries to zero.
Wrong site surgery is the demoralizing incident for the patient and family, and will have a harmful influence on the surgical team and the institution. “Time Out” is the best practice in preventing the wrong site surgeries. The “Time Out” is the final verification of the correct patient, correct procedure, correct site before making the surgical incision. This is a safety tool to prevent any harm to the patient. Research and evidence-based practice have been shown that by implementing the final verification of the surgical procedure is very successful in preventing wrong site surgeries.
By implementing the “Time Out” process, the facility has zero occurrences of wrong site surgeries. References Atkinson, R. , & Royle, J. (2007, October). Correct patient, correct side, and correct site surgery. ANZ Journal of Surgery, 77(10), 809-810. Retrieved from http://web. ebscohost. com. ezproxy. apollolibrary. com/ehost/pdfviewer/pdfviewer Makary, M. A. , Mukherjee, A. , & Sexton, B. J. (2007). Operating room briefing and wrong site surgery. Journal of American College of Surgery, 204, 236-243. Retrieved from http://www. psnet. ahrq.
gov/resource. aspx? resourceID=4853 The Association of Perioperative Registered Nurses. Position statement on correct surgery site. AORN February 2001. Available at:http://www. aorn. org/PracticeResources/AORNPositionStatements/PositionCorrectSiteSurgery/. Accessed August 10, 2010. The Joint Commission on Accreditation of Healthcare Organizations. (2003, July 21). Universal protocol established for preventing wrong site, wrong procedure, wrong person surgery [news release comment]. Retrieved from http://web. ebscohost. com. ezprox.. apollolibrary. com.