You never forget a wrong-site surgery
You never forget a wrong-site surgery
(Editor’s note: In this second part of a two-part series, we tell you how one facility avoided a wrong-side surgery. In last month’s issue, we told you about recent court cases involving wrong-site surgery and shared lessons learned.)
It doesn’t go away from you.
These words from a surgical administrator involved in a wrong-site surgery early in his career at another facility convey the devastation that providers feel when they are involved in a wrong-site surgery.
A physician at a military hospital performed surgery on the wrong side of a wrist. "I vividly remember every second of that wrong-site surgery when the doctor flipped over the wrist," says Tom McLaren, RN, BSN, MBA, CNOR, surgical services administrator at Tallahassee (FL) Memorial Healthcare. "I remember the exact words I used with the surgeon."
Since that time, McLaren promised himself he would never let that happen again. "I always stop before surgery, read the surgical consent, and we all agree what the surgery is," he says.
At another previous facility, before the Joint Commission protocol was implemented, there was a "near miss" of wrong-site surgery.
"I had talked to all of the staff and educated them that week that if there was anything wrong with the consent, anything different on the surgery schedule, if anyone said they were going to do anything different, they had to stop and resolve it," McLaren says.
The nurse had a patient on the table who was having surgery on one kidney. The physician walked in, looked at the X-ray, and said that he was performing surgery on the wrong side. The nurse replied that the surgery was supposed to be performed on the opposite side. "The surgeon said, No. I’m looking at the X-rays, and we’re going to do this side,’" he recalls.
The nurse talked to the anesthesiologist, and they said they were not going to proceed with the operation. They began to wake the patient. The surgical tech and the nurse were instructed by the other nurse to pull back the surgical table. "At that time, the surgeon was ready to blow up," McLaren says. The tech walked over to X-ray viewer and said, "The X-rays are on backward." The surgeons said, "Oops." They proceeded with the correct operation, he adds.
The lesson is that the nursing staff have to be an advocate for the patient and they have to stand their ground, McLaren says. "If there’s any question, they have to bring everything to a stop. It takes a second to make a mistake, and they have to live with that for the rest of their lives."
The director of nursing, the medical director, and the administrator should back up surgical staff who stop to make sure a mistake is not being made, say sources interviewed by Same-Day Surgery. The surgeon may need to be reminded that it is better to be safe than sued, they add.
McLaren, who was the director of surgery, was paged when the discrepancy arose for the kidney surgery, but by the time he responded, the tech had discovered the problem with the X-ray, he says.
Nurses shouldn’t be afraid of making surgeons angry, McLaren advises. "They will absolutely respect you and thank you when you stop them from making a mistake," he says.
The aviation industry and health care industry are similar in that surgeons and pilots have roles as "captains of the ship," says David Wong, MD, MSc, FRCS(C), chair of the patient safety committee of the American Academy of Orthopaedic Surgeons in Chicago.
"Lots of times, people don’t want to speak up" when there’s a problem, he says. "But we’re getting to a change in the philosophy of having a team effort, a systems intervention, to try to prevent those types of things from happening."
Before beginning any case, have redundant checks to ensure you have the correct person and surgical site, especially in terms of laterality, says Betsy Hugenberg, BSN, MSA, RN, CIC, senior healthcare consultant with AIG Consultants, healthcare management division, in Atlanta. "Whenever you can, involve patient in verification," she advises.
Also, have a final time out before beginning the procedure so that everyone "takes a deep breath" and make sure you have the right patient, procedure, equipment in the room including any implements, and the right X-rays, Hugenberg suggests. This is not just a nursing function, she emphasizes. "It needs to be embraced by the team: surgeons, anesthesiologist, and whole OR team," Hugenberg says.
Source
For more information on avoiding wrong-site surgery, contact:
- Tom McLaren, RN, BSN, MBA, CNOR, Surgical Services Administrator, Tallahassee (FL) Memorial Healthcare. E-mail: [email protected].
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