Wrong Site Surgery

This week, the continuing education email is a little different. I think we are all on a team, and when one of us fails, we all fail.

It is up to all of us to prevent wrong site surgery. Recently, some Florida professional medical boards have adopted a policy of requiring continuing education in wrong site surgery. Enjoy the reading. There are no questions for this email.

Providence, RI — A surgeon at a Rhode Island Hospital operated on the wrong side of a man’s head after a CT scan was placed backward on an x-ray viewing box, the hospital told the state Department of Health.

New York City — A neurosurgeon twice accused of operating on the wrong side of a patient’s brain has been cleared of any wrong- doing and has had his license restored.

Tampa, FL — A man who went into a Tampa area hospital for surgery to amputate one foot badly afflicted by gangrene had the wrong foot removed.(He also needed the left foot amputated as well. But he signed to do the right one first, CB)


REAL NEWS, REAL HORROR. Wrong-site surgery has a way of making headlines and grabbing attention, as these reports from the Associated Press did. For patients, families, surgeons, the nursing staffs, hospital administrators, and the general public, these are the medical errors that strike fear in the hearts of all involved.

Do they happen? Yes, they do. How often? In a healthcare system that sees 44,000 to 98,000 deaths annually as a result of medical errors, according to the 1999 Institute of Medicine report, To Err Is Human: Building a Safer Health System, wrong-site surgeries are relatively rare. The Joint Commission on Accreditation of Healthcare Organizations collected data between January 1995 and October 2001 and reported 152 adverse events involving wrong-site surgery during that time period. More than half of the errors occurred in either a hospital-based ambulatory surgery unit or a freestanding ambulatory setting. Twenty-nine percent occurred in the inpatient OR.

Three-fourths of these errors were procedures performed on the wrong body part, 11% were on the wrong patient, and 11% were the wrong operations entirely, says the Association of periOperative Registered Nurses (AORN).

“It is true wrong-site surgery is not only about the right site,” says Elizabeth Jillson, RN, BSN, perioperative nursing educator at Hackensack University Medical Center (HUMC), in Hackensack, NJ. “It also means having the right patient and the right procedure.” As an OR educator, Jillson acknowledges the recent attention focused on the issue but says, “This is not a recent development. Doing the right procedure on the right person has always been a priority in the OR. We have always seen it as a multidisciplinary responsibility for all of the different professionals who are involved in the OR.”

System Breakdown

What are the lapses that contribute to wrong-site surgery? Errors are rarely the fault of an individual; more often, they’re a breakdown in the system. According to AORN, some of the practices that may factor into wrong-site surgery include inadequate patient assessment, inadequate medical record review, lack of institutional controls, miscommunication among members of the surgical team and the patient, exclusion of certain team members, and reliance solely on the surgeon for determining the correct surgical site. Other factors that increase the risk for error include having more than one surgeon involved in a procedure, performing multiple procedures on multiple parts of a patient during a single operation, unusual time pressures, pressures to reduce preoperative preparation time, patient characteristics requiring unusual equipment or patient positioning, failure to include the patient and family or significant others when identifying the correct site, and incomplete or inaccurate communication among members of the surgical team.

Completing the Process

Perioperative nurses understand the importance of completing each step from start to finish. “If there is a discrepancy anywhere along the process,” Jillson insists, “everything stops until we make sure we are doing the correct procedure for the correct patient.” And the process begins long before the patient is wheeled into the OR. “The correct sequence of events begins with the booking of the surgery in the scheduling office,” explains Anny Yeung, RN, MPA, CNOR, CNAA, assistant vice president of perioperative services and associate hospital director at the State University of New York (SUNY) Downstate Medical Center. “It starts with the correct information on the consent [form] and the OR schedule.” In the preoperative setting, patient identification is confirmed by the nurse with name, medical record number, and date of birth. The patient’s statement of what procedure is to be done is confirmed with the surgical schedule and consent, and a thorough patient assessment is completed before the patient leaves the preoperative setting.

Recently, JCAHO recommended one person be responsible for the OR checklist. “In our hospital,” says Terri Fregletti, RN, BS, administrative director of perioperative service at the Institute for Breast Care at HUMC, “the circulating nurse is responsible for that checklist.” The checklist ensures each discipline involved has performed verification and completed documentation.

Backward x-ray films have been implicated in some of the more infamous wrong-site surgeries. At both Hackensack and SUNY Downstate, the placement of the films lies solely with the surgeon. “The surgeon is the one who will put up the x-rays,” says Maureen Ciardella, RN, BS, nurse manager of inpatient OR and orthopedic surgery at HUMC. “In addition to being totally responsible for the placement on the viewing box, surgeons confer with circulating and scrub nurses by verbally repeating the site of the surgery.”

Patient and family involvement is a key aspect in the prevention of errors. By the time the patient reaches the holding area, the patient’s name, surgical procedure, and site have been verbally verified by the preoperative nurse, the anesthesiologist, the surgeon, and the OR nurse.

Do patients ever comment on all of those questions? “Patients do sometimes question the multiple checks,” Jillson says, “but in light of the recent stories in the press, patients appreciate their own involvement.” Ciardella agrees: “By the time they get to the actual OR with the circulating nurse, patients will say, ‘Wow, you’re the fourth person to ask me that, but I’m happy to see everybody is following through and checking.’”

Indeed, patient involvement in identifying the correct site tops the list of risk-reduction strategies recommended by AORN. Others include using a specified, clear, indelible method for marking the correct site, and a facility policy and procedure on how, when, and by whom the surgical site is to be marked. It also includes the use of a verification checklist immediately before surgery that includes —

  • verbal communication with patient and/or family
  • medical record review
  • consent review
  • review of diagnostic imaging films
  • direct observation of marked surgical site
  • verbal verification of correct site with each member of the surgical team
  • the use of quality control initiatives to monitor compliance with protocol

“After all,” says Yeung, “you can have a nice protocol, but if it’s not being followed and you’re not aware of it, you can’t make any improvements.” To ensure compliance at SUNY Downstate, chart reviews are conducted each month. “From these reviews,” says Yeung, “we bring issues to the OR committee to discuss, evaluate, and implement new action plans.” A recent recommendation from the chart review process included a plan on how to mark surgical sites more consistently.

Teamwork Is Everything

Orthopedic surgeons have a special interest in preventing wrong-site surgery, too.

Of 126 cases investigated by JCAHO, 41% involved orthopedic procedures. In 1997, the American Academy of Orthopedic Surgeons first issued independent recommendations in 1997 on marking surgical sites. Going one step further, the orthopedic surgeons at Hackensack recommend not only marking the right site on the patient, but also writing “NO” on the wrong site.

Will it help? One thing all nurses learn is how to watch for the clues, the signs of trouble ahead. In a fast-paced, risky, and stressful OR environment, all warnings are welcomed. “If, even after checking the site with the patient, with anesthesia, and with the OR nurse and then marking the site with the surgeon,” Fregletti says, “we all go dyslexic and drape the wrong limb, there would be the “NO,” and everyone would see it; everyone would stop.”

Stopping is the key. “When things are not flowing in the normal manner,” Jillson says, “when there is anything out of the normal, it is a sign for everyone to stop, slow down, double-check, and make sure.”

And when the worst happens? “Any untoward or unexpected outcome is reported to the serious incident committee,” says Fregletti. “It meets and deems [the error] either a sentinel event or a serious incident.” The group will look at the systems involved that may have led to the error, perform a review or root-cause analysis, change the process, and reeducate. “Finally,” Fregletti says, “a quality review is done to make sure the process is learned and sticks.” In addition, nurses use errors that occur at other institutions to educate the staff. “We try hard,” Jillson adds, “to learn from other people’s mistakes.”

And what does nursing bring to the process? “Nurses are used to being team players,” Jillson says, “while other professions are more used to the solo practitioner role. That has been a real challenge in the OR setting — having all disciplines see themselves as integral members of the system and team.”

Tom Russell, MD, executive director, American College of Surgeons, agrees, writing in a March 22, 2002, JCAHO alert, “It is important there be cooperative openness between the surgeon and the nurses. The two groups must both take responsibility; and if there are questions, they should stop and clarify to be sure everyone is on the same page. No one should make assumptions.”

“Nurses lead by example,” Jillson says. “We have a long history of being team players.”

Carol Dunbar, RN, CNS, is a contributing writer for Nursing Spectrum

  5 comments for “Wrong Site Surgery

  1. Chris Carr
    April 30, 2010 at 3:02 PM

    Interesting. Not sure how you get ceu’s for these; if in fact we do get anything for reading this. Would like to know. Thanks Chris

  2. admin
    April 30, 2010 at 3:21 PM

    At the moment, these articles are examples of the types of content that will arrive via email. Our aim is to provice these CEU opportunities on an automatic delivery that you can then just respond to. We are still working the kinks out of the system. Until then, you can send your information via the contact page and seek credit in that regard.

  3. Arlene Kunszt
    February 19, 2011 at 11:07 PM

    After reading this article, I was unaware of how often they occur. I have heard of wrong site surgery but not wrong patient nor wrong procedure. So many individuals are involved in the surgical process that I can understand how a breakdown in the system can occur. Communication and teamwork is a group effort and each individual is a vital part of the group.

  4. chrismoses1@verizon.net
    December 25, 2012 at 12:12 AM

    Many medical centers in which I have worked all adhere to the policy of “TIME OUT” in which the staff is responsible for completing the time out form to identify that they have the right patient, right proceedure,right location. This is similar to the old rule of the five rights before giving a medication.

  5. cdasilva@challiance.org
    January 9, 2014 at 3:38 PM

    We have “Time Out”. Repetitive questions are the key. And yes patient are impressed with the thoroughness

Leave a Reply