Best practices for preventing wrong site, wrong person, and wrong procedure errors in perioperative settings

AORN Journal,  July, 2006  

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Wrong Site

Case Study 1

As the circulating nurse, I did not go to see the patient immediately after a previous case. The anesthesiologist insisted that the patient must be seen immediately and brought into the OR. The charge nurse informed me that I must see the patient and bring the patient to the room immediately. I was now feeling upset and rushed. I verified the procedure, site, and side verbally with the OR team. The surgeon left the OR to scrub, and I started prepping the patient's left limb. When the surgeon came back into the OR for gowning, he reiterated that the procedure was on the right limb. I stopped the prep, reconfirmed the site, and prepped the correct limb.

Case Study 2

I was preparing the OR for the next patient and had several pieces of equipment to set up, which was taking some time. In the meantime, the patient was brought into the OR. Before I could acknowledge the patient's presence or review the patient's chart, check the consent, and confirm the surgical site, the surgeon proceeded to prepare the patient for surgery by positioning and doing the skin prep. As the surgeon completed the prep, he removed the drapes that had been used to cover the nonoperative site. It was at this stage that I noticed the wrong area had been prepared. I pointed this out to the surgeon, and we reconfirmed the surgical site. The correct area was prepped, and the operation went ahead as planned.

Wrong Person

Case Study 3

It was a very busy day in our OR. Our supervisor was pushing to get the rooms turned over quickly to get on with the next case. The nurses were very rushed; we were short-staffed, and many of the nurses on duty had worked full shifts on the previous day and had been called in again during the night. We did not have enough staff to relieve the nurses who had worked all night. The anesthesiologists were in a similar situation. Some staff members had worked more than 16 hours in the previous 24-hour period.

I was going to the preoperative holding area to get my next patient, who was scheduled to have surgery on her arm. When I got there, my patient was not in the space that had been assigned to her; the stretcher and patient were gone. I asked the nurse in the preoperative holding area if she had checked the patient in or if someone had moved her to another area. She said the patient had been checked in, but she did not know whether anyone had moved her to another area. Together we looked for the patient. When we determined that she was not in the holding area, I had a sinking feeling that someone might have taken the wrong patient to another OR.

The OR supervisor and I ran from room to room, frantically looking for my patient. The second room I entered had a patient in lithotomy position, already shaved and prepped. They were just gowning the surgeon when I asked, "Are you certain you have the correct patient?" The surgeon said the patient was already asleep and draped when he came in. He added that her face did not look like his patient, but he didn't think much about it. The anesthesiologist said that he did not check the armband; he had assumed the circulator had the correct patient. They were rushed because we were behind schedule, so he had gone ahead with the anesthesia before the surgeon came in. The anesthesiologist immediately checked the armband, and we found that it was indeed my patient, who was to have surgery on her arm. She was 28 years old, and they were about to do a total vaginal hysterectomy on her!

The circulator admitted that she had not checked the armband, but she had asked the patient, "Are you Mrs. X?" and the patient said, "Yes." The circulator also asked, "Are you having a vaginal hysterectomy?" and again, the patient said, "Yes." So the circulator had brought the patient back to the OR without checking her armband. The anesthesiologist had not checked her armband. The surgeon did not speak with the patient or check the armband before induction of anesthesia. The patient's family had stepped out of the holding area to go to their car when the nurse came to get her for surgery. It turned out the patient could not speak or understand English and had only said yes because it was the only word she knew.

We did prevent her from having the total vaginal hysterectomy, but I shudder to think what would have happened if I had been just two or three minutes later in going to get my patient. The patient did not have surgery on her arm that day. I cannot imagine how she felt when she was told what had happened and why her perineum had been shaved.

Case Study 4

The schedule was especially busy. Two operating rooms in the same area of the OR suite had different orthopedic teams in each room. The RN circulator in OR One sent for the next patient for Surgeon One but made a mistake in the patient's name because she looked at the list of patients for OR Two. The patient scheduled for OR One was to have a total hip arthroplasty; however, the RN selected the name of a patient who was having the same procedure by Surgeon Two in OR Two. When the patient arrived in the OR, another nurse met the patient and proceeded to assist the anesthesia team with the spinal anesthetic procedure. As the patient was about to be draped for the surgery by the team for Surgeon One, the anesthesiologist spoke to the patient and called him by the name of the patient on Surgeon One's list. When the patient did not respond to his name, the nurse explained, "This is Mr. Y," using the actual name of the patient. The anesthesiologist became suspicious because Surgeon One had only one patient left on his list, and his name was Mr. Z. When the mistake was realized, Surgeon One informed Surgeon Two, and Surgeon Two carried out the surgery on his patient in OR One.