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Ensuring correct site surgery
Rita C. ScheidtMarie asked herself repeatedly, "will life ever be the same again?" Jared, her seven-year-old son, had undergone surgery. It was supposed to be simple. They said he would be in and out of surgery in no time. Jared hurt his right knee last year. The physician applied a splint to Jared's knee; however, although it seemed to have healed, Jared continued to have problems walking, and the pain limited his mobility. The physician recommended surgery to repair the injury so Jared could walk better and live without pain. Being developmentally handicapped made Jared special, and raising Jared presented Marie and her family members with one challenge after another. Jared's limited verbal skills made communication with him particularly difficult. He was impulsive and his behavior was unpredictable.
The decision to have the surgery was made after many weeks of considering the various treatment options. Marie and her husband planned carefully for the days and weeks after surgery. Normal recovery would tax family members, even under the best circumstances. Now, after surgery, Jared was even more physically handicapped. Why? When Jared had his surgery, they operated on the wrong knee and then had to operate on the injured knee also. Now, Jared and his family members were struggling with the incredible hardship of dealing with Jared's recuperation with two immobilized knee joints. Imagine the implications and consequences of an event that never should have happened--an event that was completely and totally preventable.
Though Marie's story is fictional, what if it were true? Unfortunately, such true stories do exist. Nurses, especially perioperative RNs, are in a unique position to help prevent such tragedies. Perioperative RNs must act as patient advocates to ensure that wrong site surgery does not happen. This article discusses the issue and demonstrates how to ensure correct site surgery.
A BRIEF HISTORY OF WRONG SITE SURGERY
There is no such thing as minor surgery, or so the saying goes. As an intervention, surgery never is simple because it is an insult to the integrity of the body. Since surgery was first performed, there have been complications. These complications may be due to the natural course of the disease process involved, the nature of the surgical intervention used, or unfortunate outcomes related to human error caused by a system failure. Often, the problem is a result of multiple small factors. When these small factors combine, an adverse event, such as wrong site surgery, occurs.
In 2000, the Institute of Medicine published To Err is Human: Building a Safer Health System, a report that focused on the high rate of medical errors in the United States. This report was a result of the Committee on Quality of Health Care in America's larger effort to address health care quality issues. (1) The report stunned the medical community and the public not only because of the high number of medical errors and the related financial cost, but also because of the unimaginable toll in pain, human suffering, and even death. Furthermore, the report led to many initiatives in government (eg, the Patient Safety Act), the health care industry, and the public domain to reduce the number of medical errors and make patient safety a primary goal.
Nurses play a key role in providing safe patient care. The American Nurses Association (ANA) states in the Code of Ethics for Nurses with Interpretive Statements says that "the nurse's primary commitment is to the patient, whether an individual, family, group, or community" and, "the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient." (2) These two statements summon every nurse to pay attention to, know, and adhere to the professional standards that define nursing practice. This includes knowing the provisions of their state's nurse practice act, relevant professional nursing standards (eg, AORN standards for perioperative nurses), and their implications for the practice of nursing.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) defines wrong site surgery as any surgery performed on the wrong site or patient or performing the wrong procedure. (3) To address the problem of medical errors, JCAHO introduced its sentinel event policy in 1996. This policy provides a mechanism for hospitals to self-report sentinel events, such as falls, patient injury or death in restraints, transfusion errors, anesthesia-related events, medical equipment errors, and wrong site surgeries. When a sentinel event occurs, it is subject to review under the JCAHO sentinel event policy, and this review includes a root cause analysis. The goals of such an analysis are to
* determine how the event happened,
* identify educational needs or goals,
* clarify what factors contributed to the event,
* discover risk factors, and
* determine how to prevent the event from occurring again.
This process also provides information necessary to initiate global changes in the delivery of health care to ensure positive patient outcomes.
The actual incidence of wrong site surgery is unknown. The Physicians Insurers Association of America documented the incidence of wrong site surgery claims from 1985 to 1995. They examined data from 22 medical malpractice carriers representing 110,000 physicians and found 225 claims for orthopedic wrong site surgery and 106 claims for other surgical specialties. (4) Since the initiation of the Sentinel Event Policy in 1996, JCAHO has tracked and compiled information regarding wrong site surgery. Since January 1995, 197 wrong site surgeries have been reported through JCAHO's sentinel event reporting system. These events occurred in all types of surgical settings. The Joint Commission reports that 58% occurred in ambulatory settings, 29% occurred in inpatient ORs, and 13% occurred in other inpatient settings. (5) The reports include information regarding risk factors and root causes and provide recommendations for ensuring correct site surgery. According to JCAHO, out of 126 instances of wrong site surgery, the percentage of occurrence for each surgical specialty was
* 41% orthopedic or podiatric;
* 20% general surgery;
* 14% neurosurgical;
* 11% urological; and
* the remainder occurred in dental/oral maxillofacial, cardiovascular/thoracic, otorhinolaryngological, and ophthalmic procedures. (6)
The all inclusive goal of ensuring patient safety in the perioperative setting must include the secondary objective of eliminating all instances of wrong site surgery. As a result of heightened awareness, health care facilities providing perioperative services must develop and implement policies and procedures to ensure correct site surgery. The RN working in the perioperative setting is in a unique position to influence processes required to ensure safe passage through the surgical experience.
Though a policy governing surgical site verification goes a long way toward ensuring correct site surgery, perioperative RNs must have a comprehensive understanding of the issues that must be addressed to ensure correct site surgery. Such understanding allows for effective patient advocacy and enables perioperative RNs to ensure patient safety. Furthermore, educators in perioperative areas have a responsibility to facilitate the education of all OR staff members. Education enables cooperation, collaboration, and mutual support in the shared effort to eliminate wrong site surgery.
HOW DOLES WRONG SITE SURGERY HAPPEN7
Unfortunately, wrong site surgery happens. Although policies for surgical site verification exist, there is no guarantee that surgery will be performed on the correct site. The reality is that sometimes policies are not followed. Conversely, policies may be ineffective because they do not include all necessary elements to ensure effectiveness. The following discussion identifies factors that can increase the risk of wrong site surgery, including
* exclusion of certain surgical team members from patient assessment and teaching;
* failure to include the patient or family members when identifying the correct site;
* having more than one surgeon involved in the procedure;
* inadequate patient assessment;
* inadequate medical record review;
* incomplete or inaccurate communication among members of the surgical team;
* lack of institutional policies and controls;
* miscommunication between members of the surgical team and the patient;
* performing multiple procedures on multiple parts of a patient during a single surgical encounter;
* pressure to reduce preoperative preparation time;
* problems related to illegible handwriting;
* reliance solely on the surgeon for determining the correct surgical site;
* special patient characteristics (eg, physical or mental challenges, morbid obesity);
* unusual equipment or setup in the OR;
* unusual time pressures or emergencies; and
* use of abbreviations related to the surgical procedure, site, or laterality. (7)
This list of 16 contributing factors is sobering. In the real world of day-to-day practice, perioperative RNs experience conditions that are rife with elements that could lead to wrong site surgery.
Review each factor from the previous list and imagine the following circumstances. The perioperative department is busy and under pressure to get procedures started quickly. Staff members are fatigued and under pressure. They question what is documented in the patient's medical record and whether laterality is documented? The physician says, "Prep the left knee ... I am going to take this call. Come on let's hustle! I was here until 4 AM this morning, and I have to be in my office at 9 AM." The RN notices that the schedule indicates that the procedure is to be performed on the right knee, but the consent appears to indicate the left. She points out the discrepancy, and the physician tells her again, in an unpleasant tone, that the procedure is to be performed on the patient's left knee. What should she do?
The standards of professional nursing practice require the RN to question and clarify the situation. Most facilities have policies in place that describe how to proceed when there is a disagreement between physician and nurse. In this hypothetical situation, the path to take is clear; however, what if other factors complicate the situation? If the diagnosis on the patient's medical record is inconsistent with the consent, the RN must pursue actions that will clarify the situation for the patient's sake, not simply to reduce the risk of malpractice and liability claims.
Perioperative RNs must be alert and aware of potential problematic situations. What happens when the physician does not abide by the policy? What happens when short cuts are taken and items on the surgical site verification checklist are skipped or ignored? The RN must advocate for the patient to ensure patient safety. This may mean that the RN must pursue assistance by contacting the supervisor or manager and, if the results are unsatisfactory, by engaging the next level in the chain of command. The RN is responsible for acting on the patient's behalf.
Patients with more complex needs, such as older adults who suffer from comorbid conditions or dementia or patients with florid psychiatric conditions, may be unable to actively participate in their care or the verification of the correct surgical site. Patients with hearing and vision impairments also present a communication challenge. The perioperative RN has a professional responsibility to thoroughly assess and plan for patients with complex needs. Including family members and patients' caregivers contributes to patient safety. When patients' primary language is not English, RNs should use interpreters and should not depend on patients' family members because they also may have a language barrier. Most facilities have resources that can be accessed to ensure that patients have every opportunity to communicate accurately and clearly.
A patient who is morbidly obese poses a unique dilemma and treatment challenge in the OR. The patient may require specialized management, a suitable OR bed, special retractors, and extra long instrumentation. The size of the patient can serve as a distraction to even well-intentioned staff members and lead to wrong site surgery or other types of medical errors.
Some facilities may use multiple-procedure consents. This practice attempts to save time by directing the patient to cross out every procedure except the one for which he or she is scheduled. This method is used on the pretense of saving time, but it opens the door to errors and the opportunity for mistakes. The patient may not understand medical terminology or the procedures they are crossing off the permit. What if a procedure is not crossed off and this results in the patient undergoing unnecessary surgery? This is an example of a system that focuses on efficiency and not patient safety. When errors happen, they often are initiated with a small, seemingly insignificant error in judgment that then precipitates other actions resulting in often tragic consequences.
The Joint Commission identifies unusual set-ups or equipment in the OR as a factor contributing to wrong site surgery. For example, orthopedic surgery usually is performed in a specific room in the OR, but as a result of unanticipated events, the orthopedic surgeon must perform his or her procedure in another room. The alternate room is smaller, the anesthesia column is in a different place, and the surgeon wants to use alternative power equipment that is new to perioperative staff members. Perioperative staff members must arrange the room properly and be aware that changing rooms may be disorienting. When the OR is in a state of chaos, the possibility of error increases, and staff members must remain aware and vigilant to protect the patient from negative outcomes.
Many of the contributing factors listed previously address situations that easily could be remedied. Adhering to the following actions consistently helps ensure correct site surgery.
* Engage in ongoing and effective communication with members of the surgical team.
* Include the patient and encourage him or her to actively participate in the perioperative process.
* Maintain the highest standards of patient care.
* Practice interdisciplinary collaboration and cooperation.
* Use accurate and legible documentation practices.
Consider the scenario at the beginning of the article. The information provided does not include the actions or inactions of the medical, ancillary, or nursing staff members. As an RN in the perioperative area, what strikes you as significant? Following are some components of the scenario to consider.
* A comprehensive preoperative assessment must include review of informed consent and identification of the patient's and family members' educational needs.
* The patient and family members live in a continually challenged state (ie, raising and caring for a developmentally multi-handicapped child).
* The patient is considered vulnerable because of his age and handicapped status; therefore, communicating and ensuring the parent's understanding is a critical goal when providing care.
* Language and comprehension skill deficits present a challenge to including the patient in his own care. The patient could, in the appropriate context and with the help of the medical or nursing staff members, mark his own surgical site.
* Was the health care setting so busy and rushed that the surgery experience proceeded too quickly?
* Did the physician and surgical staff members present demonstrate an attitude that was too casual and cavalier?
* Did the parents have any medical background?
* What preoperative teaching could be provided and at what level?
The issues can be pertinent to all patients. Every patient has the potential of presenting with mitigating circumstances that could lead to wrong site surgery; however, when patient safety is the primary consideration and goal of the perioperative culture, incidents of wrong site surgery can be eliminated.
RECOMMENDATIONS FOR PRACTICE
The first priority in a clinical setting is to develop and implement a policy and procedure for the identification and verification of the correct surgical site. Development should be a collaborative effort including anesthesia, medical, and nursing staff members. A multidisciplinary approach provides superior cooperation and compliance. It also reduces the amount of resistance to ongoing, consistent, and correct implementation of the policy. The time to discover discrepancies and resolve them is before the patient arrives at the OR. (8) Correct site policies and procedures must include clear and specific instructions that leave no room for varied interpretations. (For more information see "Patient safety first" on page 880).
Education regarding wrong site surgery and its prevention must involve all staff members, including nurses, physicians, and ancillary staff members. Each of these groups has a unique and essential role to play in ensuring correct site surgery. (9)
Upholding the standard. The old adage, an ounce of prevention is worth a pound of cure still is good advice. Other familiar sayings, such as better safe than sorry, look before you leap, and it is an accident waiting to happen, all contain folk wisdom that point to the importance of being prepared and aware. For health care providers, protocols to ensure that everything is done that can be done to prevent the tragedy of wrong site surgery are necessary. This is evidenced by the rise in the number of cases of wrong site surgery. The rise in the number of cases could be attributed to better reporting and an increase in the number of cases presented for litigation; regardless, health care providers must uphold high standards in the delivery of patient care.
The role of patient advocate, in reality, is what it means to fulfill the role of professional RN. Registered nurses in perioperative areas are in unique positions to advocate for patients when patients are not able to advocate for themselves. Not only may patients be sedated, there also may be other contributing factors requiring nurses to pay even closer attention to the role of patient advocate, including cases in which the patient is
* an older adult,
* under unusual stress,
* in severe pain,
* confused,
* lower functioning,
* suffering from comorbid conditions that affect awareness, and
* experiencing psychiatric problems.
PATIENT SAFETY FIRST
Consider the following suggestions when developing a surgical site verification policy. Using these suggestions as guidelines in the development of a policy and procedure will help decrease the risk of avoidable errors.
* All patients having a surgical procedure shall have the surgical site, level, and laterality, if appropriate, confirmed by the entire surgical team before any surgical procedure is performed.
* A checklist will be used for every surgical encounter to document verification of the surgical site.
* The verification checklist must be completed in its entirety. Each person completing any portion of the checklist must initial that portion of the list.
* An incomplete checklist will result in the postponement of the surgical encounter until the documentation is completed.
* Any site discrepancy noted during the verification process will result in an immediate halt of the surgical encounter until the discrepancy can be satisfactorily resolved by all members of the surgical team. (10)
These guidelines can be used as a starting point for the development of a facility-specific checklist (Table 1). (11)
THE BOTTOM LINE--PREVENT WRONG SITE SURGERY
Incidents of wrong site surgery should not happen. The perioperative health care team composed of nurses, physicians, anesthesia care providers, assistive personnel, admission workers, clerks, and other ancillary staff members must make patient safety an uncompromising goal. Working together and putting the patient first will ensure correct site surgery.
Patient safety is only one of the goals of policies and procedures, and RNs can play a key role in contributing to the development of these policies and procedures. RNs contribute to safe patient care by
* knowing and adhering to professional standards of nursing practice,
* serving on committees and work groups that develop policies and procedures,
* collaborating and cooperating with all members of the health care team.
Although it portrays, a fictional patient, the opening scenario presents a situation that is not so far-fetched. Every patient enters the health care arena with his or her own special circumstances. Each patient lives a multifaceted life, facing many unique challenges daily. Although most patients have people who love and care for them, some have no one who knows or cares that they are in the hospital and facing surgery. Every patient expects to receive help and embark on a course of healing and recovery. No one expects to come to the hospital, undergo surgery, and wake up with unnecessary pain and suffering caused by the very people entrusted to care for him or her. People come for surgery believing that the health care system will help improve their health status. Nurses must uphold the highest standards and take every action necessary to prevent wrong site surgery.
Table 1
SAMPLE PATIENT SAFETY CHECKLIST
Anesthesia
Preoperative area RN care provider Surgeon
* Verify that the X X X
patient's informed
consent describes
the surgical site
and laterality, as
appropriate.
* Verbally confirm X X X
the surgical site
and laterality with
the patient and
family members.
* Review the medical X X X
record for consis-
tency in identifying
the correct surgical
site.
* Have patient or X
family member
mark the surgical
site with an indelible
marking pen as
close as possible
to the surgical
incision.
Scrub Anesthesia
Intraoperative area RN person care provider Surgeon
* Confirm patient X X X
identity, consent,
surgical procedure,
and laterality before
transfer to the OR bed.
* Review the medical X X
record for consistency
in identifying the correct
surgical site.
* Review imaging X X
studies and confirm
surgical site.
* Require surgical X X X X
team timeout
immediately before
the incision or start
of the procedure for
final confirmation of
the surgical site.
NOTES
(1.) Institute of Medicine, To Err is Human: Building a Safer Health System (Washington, DC: National Academy Press, 2000).
(2). Code of Ethics for Nurses with Interpretive Statements (Washington, DC: American Nurses Publishing, 2001) Also available at http://www.nursingworld.org/ethics/chcode.htm (accessed 15 July 2002).
(3.) "Risk management skills help reduce surgery on the wrong operative site," Healthcare Risk Manager 3 (Fall 1999) 2-3.
(4.) Joint Commission on Accreditation of Healthcare Organizations "A follow-up review of wrong site surgery," in Sentinel Event Alert, no 24, http: //www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_24.htm (accessed 25 July 2002).
(5.) Joint Commission on Accreditation of Healthcare Organizations "A follow-up review of wrong site surgery."
(6.) Joint Commission on Accreditation of Healthcare Organizations, "Lessons learned: Wrong site surgery," Sentinel Event Alert, no 6, http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_6.htm (accessed 25 July 2002); ECRI, "Operating room risk management," Sentinel Event Alert, no 6. Also available at http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_6.htm (accessed 25 July 2002); "AORN position statement on correct site surgery," in Standards, Recommended Practices, and Guidelines, in press.
(7.) Joint Commission on Accreditation of Healthcare Organizations, "Lessons learned: Wrong site surgery"; "AORN position statement on correct site surgery."
(8.) "AORN position statement on correct site surgery."
(9.) Ibid.
(10.) Joint Commission on Accreditation of Healthcare Organizations, "Lessons learned: Wrong site surgery"; "AORN position statement on correct site surgery."
(11.) Ibid
RESOURCES
"Advisory statement: Wrong-site surgery," American Association of Orthopedic Surgeons, http://www .aaos.org/wordhtml/papers/advistmt/ wrong.htm (accessed 25 July 2002).
Anesthesia Patient Safety Foundation, http://apsf.org (accessed 25 July 2002).
Chassin, M R; Becher, E C. "Wrong patient," Annals of Internal Medicine 136 (June 2002) 826-833.
Institute for Healthcare Improvement, http://www.ihi.org (accessed 25 July 2002).
Institute for Safe Medication Practices, http://ismp.org (accessed 25 July 2002).
Institute of Medicine, http://www .iom.edu (accessed 25 July 2002).
Joint Commission on Accreditation of Healthcare Organizations, http://www.jcaho.org (accessed 25 July 2002).
"Medical errors and patient safety," Agency for Healthcare Research and Quality, http://ahrq.gov/qual /errorsix.htm (accessed 25 July 2002).
VA National Center for Patient Safety, http://www.patientsafety.gov (accessed 25 July 2002).
National Patient Safety Foundation, http://www.npsf.org (accessed 25 July 2002).
Quality Interagency Coordination Task Force, http://www.quic.gov (accessed 25 July 2002).
"OK plan to end wrong-site surgeries: Academy seeks unified effort with surgical groups," American Academy of Orthopedic Surgeons Bulletin 45 (October 1997). Also available at http://www.aaos.org/wordhtml/bulletin/oct97/wrong.htm (accessed 25 July 2002).
"Patient Safety First," http: //www.patientsafetyfirst.org/ (accessed 25 July 2002).
"Prevention of wrong-site surgery: Sign, mark and x-ray (SMaX)," North American Spine Society, http: //www.spine.org/smax.cfm (accessed 25 July 2002).
Examination
ENSURING CORRECT SITE SURGERY
1. When a sentinel event occurs, it is subject to
review under the Joint Commission on
Accreditation of Healthcare Organization's sentinel
event policy to include a root cause analysis.
Which of the following is not a goal of the root
cause analysis?
a. calculate the cost to the health care system
b. clarify what factors contributed to the event
c. determine how the event happened
d. identify educational needs or goals
2. The actual incidence of wrong site surgery is
a. decreasing due to better reporting.
b. increasing.
c. staying about the same over time.
d. unknown.
3. Wrong site surgery is most prevalent in which
specialty?
a. cardiovascular/thoracic
b. dental/oral maxillofacial
c. orthopedic or podiatric
d. urological
4. Although policies for surgical site verification
exist, surgery still may be performed on the
incorrect site because policies may be ineffective
if they do not include all necessary elements to
ensure effectiveness.
a. true
b. false
5. When the patient states that the surgeon is going
to operate on the right hand and the surgeon
states that the left hand is the surgical extremity,
the perioperative RN must
a. contact the family for clarification.
b. check the consent.
c. call the floor nurse who was taking care of the
patient before he or she came to the OR.
d. pursue all actions that will lead to clarification
and reduce the risk of wrong site surgery.
6. Using multiple-procedure consents is an effective
method to save time and ease communication
problems with patients for whom English is not
the primary language.
a. true
b. false
7. When errors happen, they often are initiated with
a small, seemingly insignificant error in judgement
that then precipitates other actions, often
resulting in tragic consequences.
a. true
b. false
8. If the first priority in a clinical setting is to develop
and implement a policy and procedure for the
identification and verification of the correct surgical
site, which statement is correct?
a. Administrators and managers in health care
facilities where surgery is performed are
responsible for the process.
b. This is best achieved when surgeons and nurses
collaborate.
c. This is best achieved when a multidisciplinary
approach is used and includes anesthesia, medical,
and nursing staff members.
d. RNs must take the lead and write the policy in
accordance with the nurse practice act.
9. According to the sample patient safety checklist,
which perioperative team members are responsible
for reviewing imaging studies and confirming
the surgical site?
a. scrub person, anesthesia care provider, and
surgeon
b. RN and surgeon
c. anesthesia care provider and surgeon
d. RN, anesthesia care provider, and surgeon
10. Patient safety is only one of the goals of policies
and procedures. RNs can play a key role in contributing
to the development of these policies
and procedures. RNs contribute to safe patient
care by doing all the following except
a. knowing and adhering to professional standards
of nursing practice.
b. following physician orders exactly and without
question.
c. serving on committees and work groups that
develop policies and procedures.
d. collaborating and cooperating with all members
of the health care team.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credential Center approves or endorses products mentioned in the activity. AORN is provider approved by the California Board of Registered Nursing, Provider Number CEP 13019.
[ILLUSTRATIONS OMITTED]
Rita C. Scheidt, RN, C, is the OR educator at MedCentral Health Systems, Mansfield, Ohio.
COPYRIGHT 2002 Association of Operating Room Nurses, Inc.
COPYRIGHT 2002 Gale Group