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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.
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)
RISK-REDUCTION STRATEGIES
AORN is in agreement with JCAHO and suggests that clinical facilities consider the following strategies for developing facility procedures and protocols when identifying the correct surgical site. (10)
* Involve the patient and his or her family members and significant others in identifying the correct site.
* Use a specified, clear, unambiguous, indelible, hypoallergenic, latex-free method for marking only the correct surgical site.
* Specify in individual facility policy and procedure how, when, and by whom the surgical site is to be marked.
* Incorporate the following verification items in the preoperative checklist and confirm them immediately before surgery:
* verbal communication with the patient and his or her family members and significant others;
* medical record review, including the face sheet, history and physical, and preoperative assessment;
* review of the informed consent;
* review of all available imaging studies;
* direct observation of the marked surgical site;
* verbal verification of the correct site by each member of the surgical team; and
* the surgical team's "time-out" immediately before the incision or start of the procedure for final confirmation of the surgical site."
* Use quality control initiatives to monitor compliance with protocol.
* Establish a process to address and clearly resolve any discrepancies noted during the verification process before beginning the procedure.
IMPLEMENTING A POLICY AND PROCEDURE FOR CORRECT SITE SURGERY
AORN is committed to promoting identification of the correct surgical site. Using the suggested risk-prevention strategies when developing policies and procedures will reduce the risk of error. As patient advocates, perioperative RNs should communicate with all members of the surgical team to verify the correct surgical site. Individual facility policy should clearly delineate the role and responsibility of the physician and other team members in marking and verifying the correct surgical site.
Members of the multidisciplinary team must work together in a collaborative manner, obtaining high levels of agreement from all key stakeholders to establish a "best practice" protocol for identifying and verifying the patient's identity and surgical procedure, site, and laterality. Successful implementation relies on team member involvement at each step of the process, from the policy-setting phase of the effort through implementation and evaluation.
After a draft policy and procedure is developed, it should be reviewed by key stakeholders in the facility, including the chief executive officer, the risk manager, the nurse executive, the director of quality management, chiefs of surgical services, and anesthesia staff members. Key points of any policy should address
* who is responsible for involving the patient and his or her family members and significant others in identifying the correct site;
* how patient identity will be confirmed;
* what type of clear, unambiguous, indelible, hypoallergenic, latex-free method will be used for marking only the correct surgical site;
* how, when, and by whom the surgical site is to be marked;
* who is responsible for confirming the presentation, identity, and labeling of imaging studies;
* the process for having the surgical team take a "time-out" immediately before the incision or start of the procedure for final confirmation of the surgical site; (12)
* the process and communication channels to promptly address and clearly resolve any discrepancies noted during the verification process before beginning the procedure;
* processes for training staff members and validating their competency;
* procedures for reporting and responding to wrong site surgery or near misses; and
* how monitoring of compliance will be performed on an ongoing basis.
After this policy is identified and documented, all members of the multidisciplinary team must agree on processes to manage situations of nonadherence to the written protocol. For example, if a surgeon does not adhere to the policy, administrators must apply preidentified sanctions. If a nurse does not complete the verification checklist properly, the sanctions must be clear and applied consistently. A policy and procedure has the greatest potential for reducing risks related to wrong site surgery if team members support the importance of standardizing the process and are committed to adhering to the procedure and, thus, to patient safety. After the policy is established, every member of the surgical team needs to clearly understand his or her role and responsibility in carrying out the procedure. Staff member orientation to the policy and procedure and competence assessment also must occur at all levels to ensure knowledge of and compliance with correct site policies and procedures. Such education and training assessment must occur with all members of the perioperative health care team.
Successful implementation of any change in policy or practice requires careful planning and coordination. A protocol related to correct site surgery involves all members of the health care team in surgical settings.
Table 1
ORGANIZATIONS WITH CORRECT SITE SURGERY RECOMMENDATIONS
Organization Mailing address Web site
American Academy PO Box 7424, http://www.aao.org
of Ophthalmology San Francisco, CA
(AAO) 94120-7424
American Academy 6300 N River Rd, http://www.aaos
of Orthopaedic Rosemont, IL .org
Surgeons (AAOS) 60018-4262
American 1444 Eye St NW, http://www.aaeeh
Association of Eye Suite 410, .org
and Ear Hospitals Washington, DC
(AAEEH) 20005
American 5550 Meadow- http://www.neuro
Association of brook Dr, Rolling surgery.org
Neurological Meadows, IL
Surgeons (AANS) 60008-3845
American College of 633 N St Clair St, http://www.facs.org
Surgeons (ACS) Chicago, IL 60611-
3211
American Society of PO Box 193030, http://www.asorn
Ophthalmic San Francisco, CA .org
Registered Nurses 94119
(ASORN)
AORN 2170 S Parker Rd, http://www.aorn.org
Suite 300, Denver,
CO 80231-5711
Joint Commission One Renaissance http://www.jcaho
on Accreditation of Blvd, Oakbrook .org
Healthcare Terrace, IL 60181
Organizations
(JCAHO)
North American 22 Calendar Ct, 2nd http://www.spine
Spine Society Floor, LaGrange, IL .org
(NASS) 60525
Organization Telephone number Comments
American Academy (415) 561-8500 Collaborates with ASORN
of Ophthalmology and AAEEH in a joint state-
(AAO) ment, available at http://
webeye.ophth.uiowa.edu/
ASORN/Safety/SafetyBulletin
1.htm
American Academy (800) 346-2267 Statement available at http
of Orthopaedic ://www.aaos.org/wordhtml
Surgeons (AAOS) /papers/advistmt/wrong.htm
American (202) 347-1993 Collaborates with ASORN
Association of Eye and AAO in a joint state-
and Ear Hospitals ment, available at http://
(AAEEH) webeye.ophth.uiowa.edu/
ASORN/Safety/SatetyBulletin
1.htm
American (888) 566-2267 Information available at
Association of http://www.neurosurgery.org
Neurological /aans/bulletin/spring01
Surgeons (AANS) /neuroliability.html
American College of (312) 202-5000 Statement being developed
Surgeons (ACS) and reviewed
American Society of (415) 561-8513 Collaborates with AAO and
Ophthalmic AAEEH in a joint statement,
Registered Nurses available at http://webeye
(ASORN) .ophth.uiowa.edu/ASORN/
Safety/SafetyBulletin1.htm
AORN (800) 755-2676 Statement available at
http:/www.aorn.org/
positions/correctsite.htm
Joint Commission (630) 792-5000 Sentinel Event Alert, "A fol-
on Accreditation of low-up review of wrong site
Healthcare surgery," available at http://
Organizations www.jcaho.org/about+us/
(JCAHO) news+letters/sentinel+event
+alert/sea_24.htm
North American (877) 774-6337 Statement available at http
Spine Society ://www.spine.org/smax.cfm
(NASS)
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.
(15.) Ibid.
(16.) Ibid; 1.
(17.) Ibid; "Sentinel events," SE-2.
COPYRIGHT 2002 Association of Operating Room Nurses, Inc.
COPYRIGHT 2002 Gale Group