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Patient Safety Tip of the Week
June 13, 2023 Preventing
Wrong-Site Surgery
A patient was taken to the OR for a
right-sided craniotomy for drainage of subdural hematoma (CDPH 2022). A burr hole was erroneously drilled on the left side of the
skull before the error was realized. When no drainage was noted coming out of
the burr hole on the left side of the patient's head/skull, it was then the
surgical team realized the burr hole was done on the wrong side. The patient
then had a burr hole drilled on the right side for evacuation of the subdural
hematoma. Investigation revealed that there was no site marking performed prior
to the surgery.
Interview with a Licensed Nurse indicated it was the
hospital's policy to do the pre-op checklist before the patient goes to
surgery. The nurse further indicated the unit was short staffed and the
hospital fired all the ancillary staff, which has affected patient care. The
nurse stated, "We were swamped and had no secretaries to answer phones,
the patient became combative, and I did not fill out the pre-op
checklist."
Further, the nurse stated, "The surgeon normally marks
the site, but we had no surgical marking pens in unit. I had never seen those
pens before, we only had sharpies." The nurse further stated, "The
surgeon took responsibility and indicated he did not mark the site and
performed surgery on the wrong site."
The patient was brought to the OR and while on the OR table,
the patient's hair was clipped, site was prepped, and the patient was draped by
the surgeon and the physician’s assistant. At this point the site could have
been marked.
Details were not provided about the expected surgical
timeout in the OR. If it was done, it obviously skipped the required step of
verifying the site marking.
That failure to correctly perform a surgical site marking is
one of three common team errors leading to wrong site surgery, according to
Joint Commission Chief Patient Safety Officer and Medical Director Haytham Kaafarani, MD, MPH, FACS in an interview with AORN staff (AORN
2023). Those 3 team errors are:
·
Lack of full team attention during Time Out
·
Inaccurate and non-visible site marking
·
Not instilling a “speak up” culture, especially
among new team members
Kaafarani notes that certain sites
are more difficult to mark (see our May
14, 2019 Patient Safety Tip of the Week “Wrong-Site Surgery and
Difficult-to-Mark Sites”)
and that the site marking should not be intentionally or accidentally
placed under the drape at the point of the Time Out. “Every member of the team
should confirm site marking is done, visible, and appropriate—the Time Out
should be an opportunity to recheck correct surgical site marking as a team.”
Regarding lack of full team attention during Time Out, Kaafarani notes “Time out must always be recognized as a
primary step, not an action secondary to other OR activities.” “Too often, team
members are allowed to simultaneously proceed with other activities during the
Time Out (such as continuing to drape or check the instruments and equipment)
and this lack of full attention means those team members “are not fully tuned to
communicate patient information or raise a concern.” Kaafarani
suggests enlisting one person responsible for rallying the team to fully engage
in the Time Out. That means “giving this individual the authority to remind any
team member not giving full attention during the Time Out that they need to do
so, even during a routine surgery, during any surgery.” Our own recommendation
is that the surgeon should not be that individual. We’ve seen all too
often that deference is given to the surgeon and other team members are likely
to simply nod assent to the items noted by the surgeon. That, of course, leads
to Kaafarani’s third point – not instilling a “speak
up” culture. Kaafarani notes that, given staffing
challenges in recent years, it is particularly important to encourage new
members of the team to be empowered to speak up. He emphasizes that team
members still need to be encouraged to speak up, even if their concern is wrong
(citing examples where someone is reluctant to speak up because several
previous times they spoke up were not validated).
A recent review of 68 wrong-site closed claims cases (Tan
2023) found services most frequently responsible for these were Orthopedic
(35.3%), Neurosurgery (22.1%), and Urology (8.8%). The most common types of
procedures were spine and intervertebral disc surgery (22.1%), arthroscopy
(14.7%), and surgery on muscles/tendons (11.8%). The top contributing factors
to wrong-site surgery were failure to follow policy/protocol (83.8%) and
failure to review the medical records (41.2%).
A study on insurance claims for
wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors in
France (Vacheron 2023) also showed the main specialties involved
were orthopedics (34% of cases) and neurosurgery (14%), but dentistry was
involved in 14%. The main factors responsible for errors were the team factors (87%),
followed closely by the task related factors (78%). A direct causal factor was
found in 20% of the cases. The main causes were organizational factors (19%-43%),
such as failure in the perioperative check list or during transmission of
medical information. One other major causal problem was related to the medical
file (16%-36%), containing incomplete information or simply containing misleading
information. Notably, 5 of the 6 cases of wrong-side locoregional anesthesia led
to a wrong-side error during surgery.
Concerning neurosurgery, the errors were mainly related to
vertebral surgery, mainly in the lumbar spine. Although preoperative
radiological identification of the level of the lesion in neurosurgery had been
part of the guidelines since the publication of the “Sign, Mark & X-ray”
protocol in 2001, errors remain common because of congenital anatomical
variations, overweight, or improper radiological exposure.
It probably should not be surprising that orthopedics
typically heads the list of wrong-site surgery claims. That may be in part due
to the sheer volume of orthopedic cases done and the fact that the issue of
laterality appears more often than in, for example, abdominal surgery.
Several of our columns have noted the role that surgical
booking and scheduling have in contributing to wrong-site surgery (see, for
example, our October 30, 2012 Patient
Safety Tip of the Week “Surgical Scheduling Errors”). But one orthopedic team took a unique
approach to scheduling after a wrong-side knee surgery (Gapinski-Kloiber
2022). They took a close look at the root causes of the event and
made a relatively simple change in practice to prevent it from occurring again
- they decided to schedule left knees on one day and right knees on another, so
equipment didn’t need to be switched and there was no confusion about
laterality.
A most interesting discussion of “affirmative” vs.
“negative” site marking appeared in the Washington Post a couple years ago
(Perlow
2021). Urologist David Perlow notes that
The Joint Commission’s Universal Protocol asks surgeons to sign the correct
site before surgery, a concept adapted from the “Sign Your Site” campaign
launched by the American Academy of Orthopaedic
Surgeons in 1998. But Perlow notes the issue revolves
around what happens when a patient is draped. He argues that marking the
“wrong” side would allow the surgeon to still operate on the correct side when
that mark was obscured by drapes. But a negative mark would appear if the
incorrect side was prepped and the correct side was obscured by drapes. However,
we see a flaw in that approach – what happens when neither side was marked,
such as the index case described above! A more reasonable approach would be to
mark both sides – one “yes” and one “no”.
The Joint Commission reported 85 cases of wrong surgery in
its review of sentinel events in 2022 (TJC
2023). That includes wrong site, wrong procedure, wrong patient, and wrong
implant events. It is also likely an underestimate of actual cases. Unfortunately,
solutions to the wrong-site surgery problem remain elusive and we continue to
see this sentinel event, even in some of our finest medical centers. It’s
important to understand that this is not just the surgeon’s responsibility – it
is the responsibility of every member of the surgical team, and also those
involved in OR scheduling, those ensuring that patient safety policies are
complied with, and the patient him/herself. We hope you’ll go back to our October
5, 2021 Patient Safety Tip of the Week “Wrong Side Again”
and our May 2022 What's New in the Patient Safety World column “PPSA:
Updated Wrong-Site Surgery Recommendations” for detailed recommendations on
what your organization should be doing to minimize the risk of wrong-site
surgery.
Some of our prior columns related to wrong-site surgery:
September 23, 2008 “Checklists
and Wrong Site Surgery”
June 5, 2007 “Patient
Safety in Ambulatory Surgery”
July 2007 “Pennsylvania
PSA: Preventing Wrong-Site Surgery”
March 11, 2008 “Lessons
from Ophthalmology”
July 1, 2008 “WHO’s
New Surgical Safety Checklist”
January 20, 2009 “The
WHO Surgical Safety Checklist Delivers the Outcomes”
September 14, 2010 “Wrong-Site
Craniotomy: Lessons Learned”
November 25, 2008 “Wrong-Site
Neurosurgery”
January 19, 2010 “Timeouts
and Safe Surgery”
June 8, 2010 “Surgical
Safety Checklist for Cataract Surgery”
December 6, 2010 “More
Tips to Prevent Wrong-Site Surgery”
June 6, 2011 “Timeouts
Outside the OR”
August 2011 “New Wrong-Site Surgery Resources”
December 2011 “Novel Technique to Prevent Wrong Level Spine
Surgery”
October 30, 2012 “Surgical Scheduling Errors”
January 2013 “How Frequent are Surgical Never Events?”
January 1, 2013 “Don’t Throw Away Those View Boxes Yet”
August 27, 2013 “Lessons on Wrong-Site Surgery”
September 10, 2013 “Informed Consent and Wrong-Site Surgery”
July 2014 “Wrong-Sided Thoracenteses”
March 15, 2016 “Dental
Patient Safety”
May 17, 2016 “Patient
Safety Issues in Cataract Surgery”
July 19, 2016 “Infants
and Wrong Site Surgery”
September 13, 2016 “Vanderbilt’s
Electronic Procedural Timeout”
May 2017 “Another
Success for the Safe Surgery Checklist”
May 2, 2017 “Anatomy
of a Wrong Procedure”
June 2017 “Another
Way to Verify Checklist Compliance”
March 26, 2019 “Patient
Misidentification”
May 14, 2019 “Wrong-Site Surgery and
Difficult-to-Mark Sites”
May 2020 “Poor
Timeout Compliance: Ring a Bell?”
September 14, 2021 “Wrong Eye Injections”
October 5, 2021 “Wrong Side Again”
November 9, 2021 “Ensuring Safe Site Surgery”
February 15, 2022 “Wrong-Side Chest Tubes”
May 2022 “PPSA:
Updated Wrong-Site Surgery Recommendations”
References:
CDPH (California Department of Public Health). Complaint Intake
Number: CA00736471. CDPH 2022; September 29, 2022
AORN (Association of periOperative
Registered Nurses) staff. 3 Preop Safety Errors Risking Wrong Site Surgery (And
How to Empower Improvement). AORN 2023; May 22, 2023
Tan J, Ross JM, Wright D, et al. A Contemporary Analysis of
Closed Claims Related to Wrong-Site Surgery. The Joint Commission Journal on
Quality and Patient Safety 2023; 49(5): 265-273
https://www.jointcommissionjournal.com/article/S1553-7250(23)00053-3/fulltext
Vacheron CH, Acker A, Autran M, Fuz F, Piriou V, Friggeri A, Theissen A. Insurance Claims for Wrong-Side, Wrong-Organ,
Wrong-Procedure, or Wrong-Person Surgical Errors: A Retrospective Study for 10
Years. J Patient Saf 2023 Jan 1; 19(1): e13-e17
Gapinski-Kloiber K. Why Does
Wrong-Site Surgery Keep Happening? Put policies in place to make sure surgeons
always cut where they should. Outpatient Surgery 2022; April 7, 2022
Perlow DL. Surgeons sometimes
operate on the wrong body part. There's an easy fix. Washington Post 2021;
November 27, 2021
The Joint Commission. Sentinel Event Data 2022 Annual
Review. The Joint Commission 2023
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