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

AORN Journal,  Nov, 2002  

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GLOSSARY

Sentinel event: "A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase `or the risk thereof' includes any process variation for which a recurrence would carry a significant chance of serious adverse outcome. Such events are called `sentinel' because they signal the need for immediate investigation and response." (13)

Wrong level/part surgery: A surgical procedure that is performed at the correct site but at the wrong level or part of the operative field; for example, performing a lumbar laminectomy on an unintended intervertebral level immediately adjacent to an intervertebral level with identified pathology. In this type of error, the correct part of the body is prepped and draped, but the surgical procedure is performed on the wrong level of the patient's anatomy. (14)

Wrong patient surgery: A misidentification of the patient. This type of error includes procedures that are performed on the wrong patient. (15)

Wrong side surgery: A surgical procedure that involves operating on the wrong extremity or wrong side of the body. (16)

Wrong site surgery: A broad term that encompasses all surgical procedures performed on the wrong body part or the wrong patient. (17)

NOTES

(1.) Institute of Medicine, To Err is Human: Building a Safer Health System (Washington, DC: National Academy Press, 2000).

(2.) "ANA code for nurses with interpretive statements--Explications for perioperative nursing," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2002) 53-70.

(3.) "Sentinel events," in Comprehensive Accreditation Manual for Hospitals: The Official Handbook (Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations, 2002) SE-2; ECRI, "Operating room risk management," ORRM Surgery 23 (August 2000) 1-2.

(4.) "Sentinel events," SE-2.

(5.) Joint Commission on Accreditation of Healthcare Organizations, "Lessons learned: Wrong site surgery," in Sentinel Event Alert, no 6, http://www.jcaho .org/about+us/news+letters/sentinel +event+alert/sea_6.htm (accessed 15 Sept 2002).

(6.) American Academy of Orthopaedic Surgeons, "Advisory statement: Wrong-site surgery," http://www.aaos .org/wordhtml/papers/advistmt/wrong. htm (accessed 15 Sept 2002).

(7.) 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 15 Sept 2002).

(8.) Joint Commission on Accreditation of Healthcare Organizations, "Lessons learned: Wrong site surgery"; ECRI, "Operating room risk management," 5-6.

(9.) Ibid.

(10.) Ibid.

(11.) "Sentinel events," SE-1.

(12.) Ibid.

(13.) Joint Commission on Accreditation of Healthcare Organizations, "A follow-up review of wrong site surgery."

(14.) ECRI, "Operating room risk management," 2.