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Patient safety first alert—implementing a correct site surgery policy and procedure

In 2000, the Institute of Medicine's report, To Err is Human: Building a Safer Health System, brought national attention to the need to improve patient safety. (1) AORN supports comprehensive approaches in each health care delivery system to ensure correct site surgery. Policies, procedures, and protocols should be developed collaboratively by multidisciplinary teams that include perioperative RNs, surgeons, anesthesia care providers, risk managers, and other health care professionals.

More Articles of Interest: Correct site surgery statement information - Brief Article; Ensuring correct site surgery - Patient Safety First; Information on AORN's Correct Site Surgery Tool Kit; Ensuring correct site surgery; Patient Safety Task Force Addresses Wrong Site Surgery

Perioperative RNs should be key participants in multidisciplinary teams as they develop these procedures and protocols. As patient advocates, perioperative RNs have a duty to the public to protect the patient from injury and to safeguard the patient's health, welfare, and safety. (2) A central goal of perioperative nursing is to help the patient achieve a level of wellness equal to or greater than that which he or she had before surgical intervention. Although it is the surgeon's responsibility to determine the patient's need for surgery, verifying the correct surgical site at the time of surgery is the responsibility of every health care provider.

BACKGROUND

Wrong site surgery is a broad term that encompasses all surgical procedures performed on the wrong patient, wrong body part, wrong side of the body, or wrong level of the correctly identified anatomic site. (3) The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) considers all wrong site surgeries, regardless of the extent of the procedure, to be sentinel events. As such, they are subject to review under the JCAHO sentinel event procedure. (4) This procedure calls for a root cause analysis of each sentinel event. Review of several root cause analyses by the JCAHO accreditation committee of the board of commissioners found that wrong site surgery most frequently occurs during orthopedic, urologic, and neurosurgical procedures. (5)

One of the first groups to address wrong site surgery was the American Academy of Orthopaedic Surgeons (AAOS). Recognizing that wrong site surgery is most common in orthopedic procedures, the AAOS is committed to eliminating the incidence of wrong site surgery and has developed a wrong site surgery advisory statement in which it notes that it is the surgeon's responsibility to identify and mark the correct surgical site. (6) Recognizing that wrong site surgery is not only an orthopedic problem, the AAOS called for a comprehensive effort by other surgical specialties and health care professionals to develop protocols to effectively eliminate wrong site surgery.

Other organizations and groups, including AORN, have chosen to address correct site surgery (Table 1). These groups outline a number of specific measures and processes to ensure correct site surgery. The most recent recommendations were issued by JCAHO and address four key processes as risk reduction strategies. These include

* marking the surgical site and involving the patient in the marking process;

* creating and using a verification checklist, including pertinent medical records, x-rays, and/or imaging studies;

* obtaining oral verification of the patient, surgical site, and procedure in the OR from each member of the surgical team; and

* monitoring compliance with these procedures. Additionally, JCAHO recommends that surgical teams consider taking a "time-out" in the OR to verify the correct patient, procedure, and site using active communication techniques. (7) These same recommendations are an integral part of JCAHO's recently announced 2003 national patient safety goals and recommendations.

Performing surgery on the wrong site can have serious consequences for the patient. The patient may be affected emotionally, as well as physically, by surgery performed on the wrong surgical site. An ineffective surgical site verification procedure can contribute to the incidence of wrong site surgery. Other factors that can contribute to the incidence of wrong site surgery include:

* inadequate patient assessment;

* inadequate medical record review;

* lack of institutional policies and controls;

* miscommunication among members of the surgical team and the patient;

* exclusion of certain surgical team members;

* relying solely on the surgeon to determine the correct surgical site; (8)

* having more than one surgeon involved in the procedure;

* performing multiple procedures on multiple parts of a patient during a single surgical encounter;

* unusual time pressures or emergencies;

* pressure to reduce preoperative preparation time;

* special patient characteristics, including morbid obesity or other physical challenges;

* unusual equipment or setup in the OR;

* failure to include the patient and his or her family members and significant others when identifying the correct site;

* use of abbreviations related to the surgical procedure, site, or laterality;

* problems related to illegible handwriting; and

* incomplete or inaccurate communication among members of the surgical team. (9)

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Patient safety first alert—implementing a correct site surgery policy and procedure

AORN Journal, Nov, 2002

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