Out of site, out of mind

Preventing wrong-site surgery in your hospital

Infection control professionals increasingly involved in the issue of patient safety may someday prevent the nightmare of a wrong-site surgery. According to the Joint Commission on Accreditation of Healthcare Organizations, here’s how to ensure it won’t happen at your facility. Have policies that require:

1. marking the surgical site and involving the patient in the marking process;

2. creating and using a verification checklist including appropriate documents, for example, medical records, X-rays, and/or imaging studies;

3. obtaining oral verification of the patient, surgical site, and procedure in the operating room by each member of the surgical team;

4. monitoring compliance with these procedures.

As an adjunct to these measures, ICPs and patient safety advocates may simply urge surgical teams to consider taking a "timeout" in the operating room to verify the correct patient, procedure, and site. The Joint Commission has identified a number of factors contributing to the increased risk for wrong-site, wrong-person, or wrong-procedure surgery. Those include: emergency cases (19%); unusual physical characteristics, including morbid obesity or physical deformity (16%); unusual time pressures to start or complete the procedure (13%); unusual equipment or setup in the operating room (13%); multiple surgeons involved in the case (13%); multiple procedures being performed during a single surgical visit (10%).

The root causes identified by the hospitals usually involved more than one factor. However, the majority involved a breakdown in communication between surgical team members and the patient and family. Other contributing causes included absence of policies that would address issues in the aforementioned checklist.