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Error In Judgment: Why Wrong-Site Surgery Is Still A Problem

Wed, 03/05/2014 - 7:03am
Mike Schmidt, Editor, Surgical Products

This article appears in the March print issue of Surgical Products.

Wrong-site surgery is a devastating problem that affects all parties present in the operating room. To make matters worse, it’s an all-too-common occurrence today. Although efforts have been made to address this issue, it still remains a significant one. Three industry experts recently took time to discuss adverse medical events in the OR, wrong-site surgery, and the products meant to prevent these problems.

SP: There are any number of factors that can contribute to an incident of wrong-site surgery. Which factors contribute to the most to the fact that this remains a significant problem for the healthcare industry?

Gina Santosuosso, RN, BSN, President, Patient Safety Gear, Inc.: Lack of communication, inadequate staffing, increased patient load, and time constraints contribute the most to adverse medical events. There is sometimes added pressure to work efficiently and stay on schedule for the facility, physicians, and most importantly patients. While all of these factors are present, you are still expected to deliver the same quality of care and safety to each patient. This can prove to be difficult at times, and I feel it leads to mistakes that can be easily prevented.

Patty Taylor, Vice President of Professional Education and Clinical Affairs, Ansell:  In 2013, The Joint Commission again showed wrong-site surgery as the most frequently reported sentinel event. An earlier study (2007) from The Joint Commission identifies the primary root causes of wrong-site surgery which include: communication failure (70 percent), procedural noncompliance (64 percent), and leadership (46 percent).  Today, poor preoperative planning, lack of institutional controls, failure of the surgeon to exercise due care, and communication breakdowns also contribute to this serious issue. Recent research has also demonstrated that failure is generally the result of a combination of errors rather than one single source.

SP: In your opinion, what are the best measures for a facility to employ to ensure these problems don't occur?

Taylor: Various professional organizations have established recommended practices to support the effective implementation of the Universal Protocol. In 2005, the Association of Perioperative Registered Nurses (AORN) released a Correct Site Surgery Tool Kit which provided various resources to assist healthcare providers in implementing The Joint Commission’s Universal Protocol. This tool kit was approved by the American College of Surgeons, American Society of Anesthesiologists, American Society for Healthcare Risk Management, American Hospital Association, and the American Association of Ambulatory Surgery Centers. In February 2013, an additional tool was developed by The Joint Commission to reduce the incidence of wrong-site surgery. The Targeted Solutions Tool (TST) for wrong-site surgery helps guide healthcare organizations through a step-by-step process to identify, measure, and reduce risks during their Time Out process. This tool provides healthcare facilities with a process to evaluate risks across all crucial areas: scheduling, preoperative, and the operating room. It helps identify specific areas of weakness that might lead to the risk of a wrong-site surgery.

Santosuosso: The facility should follow all recommended guidelines and implement them as best as possible to ensure the best safety practices. As a nurse you have to be an advocate for that patient and speak out on their behalf no matter what pressures you may be under in a situation. Follow all Time Out procedures before the case is started. The surgeon, anesthesiologist, and RN should all confirm the Time Out and Five Rights together to avoid any errors. It is unacceptable to skip this step prior to any procedure.

SP: Is this a problem on the rise or on the decline? Why?

Taylor: According to the Joint Commission Center for Transforming Healthcare, the incidence of wrong-site/wrong-procedure/wrong-patient surgery may be as high as 40 times per week. Many experts believe that the frequency of wrong-site surgery is not necessarily increasing, rather the actual reporting of these events may be on the rise. The increase in reporting of events may be the result of states and organizations taking steps to identify and diminish preventable errors and reduce costs associated with such incidents. On the other hand, it is unlikely that wrong-site-surgery will be fully reported due to voluntary reporting in various states, the impact on industry image, fear of litigation, and the difference of opinions between medical experts.

Santosuosso: I believe and hope it is on the decline. It is not something that can be completely eliminated but improvements are being made every day to policies and procedures. I think patients are being more proactive and involved with their care, and they are checking that these safety measures are taken to avoid adverse events. They sometimes come in and have marked their own limbs prior to surgery, writing with a pen or marker in fear of the worst.

SP: What types of products are most effective at preventing wrong-site surgery?

Mary Hannon, Marketing Manager, Aspen Surgical: Surgical skin markers are one of the most prominent products used to support correct-site surgery.  Such products are used to mark the surgical site prior to skin prep. They can be used as part of the Joint Commission’s Universal Protocol to help ensure staff is performing the correct procedure on the correct patient. Because this is done prior to the patient even entering the operating room, it could be considered one of the first steps in providing clear communication in order to avoid wrong-site surgery.  Within the skin marker category, a variety of ink, tip, and body styles are now available to meet the varying needs and preferences of hospital staff. In addition to surgical skin markers, there are also a series of products designed to help assist in the Time Out process required by the Joint Commission. Products that support this process include highly visible towels, beacons, and instrument covers that can be placed over the surgical instrument site, tray, or instrument.  In this way, they serve as a reminder of the importance of performing a Time Out.

SP: Are the standards, protocols, and processes out there enough to effectively prevent these problems from occurring? Why or why not?

Taylor: Healthcare professionals have an obligation to comply with the Joint Commission’s Universal Protocol. Current standards, protocols, and processes will be more effective when barriers to implementation are addressed and eliminated. If all healthcare facilities adopt and enforce the Universal Protocol and surgical teams are consistently in compliance, a significant reduction in wrong-site surgery is possible.

Have any thoughts on this article? E-mail me at mike.schmidt@advantagemedia.com  or respond on Twitter @MikeSchmidt_SP.

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