Wrong-site protocol is more than one year old, but problems mount
Wrong-site protocol is more than one year old, but problems mount
1 hospital’s accreditation conditional, partly due to not following protocol
(Editor’s note: In this first part of a two-part series on wrong-site surgery, we tell you about recent court cases and what can be learned from each. In next month’s issue, we’ll tell you how one facility avoided a case of wrong-side surgery.)
A wrong-site, wrong-procedure, and wrong-person universal protocol has been required by the Joint Commission on Accreditation of Healthcare Organizations since July 2004 and supported by multiple national organizations, but adverse events continue. This year, one hospital received conditional accreditation after the surveyors noted several problems, including the protocol not being followed, according to the inspection report released to a local newspaper.1
Joint Commission surveyors gave the hospital conditional accreditation after they found violations of 23 standards, including problems making sure the correct hardware was used in a knee replacement.
"The main risk reduction strategy to help to reduce this is going to be adherence to the universal protocol, as well as having a culture that supports all members of team speaking up for patient safety if they think there’s a problem, so no one is afraid to raise his or her hand or slow down the procedure," says Betsy Hugenberg, BSN, MSA, RN, CIC, senior health care consultant with AIG Consultants, Healthcare Management Division, in Atlanta. Hugenberg shared risk management strategies at the most recent meeting of the Federated Ambulatory Surgery Association (FASA).
So far in 2005, an average of 4.3 reports of wrong-site surgery has been received by the Joint Commission each month, the agency reports.
Same-Day Surgery discussed recent cases, including one in which a $1 million verdict was awarded, with leaders in the field to determine what lessons can be learned:
• Surgeon sued for wrong-site operation.
A Florida surgeon was to repair a woman’s ruptured left Achilles tendon, according to a media report.2 The patient was anesthetized while she was lying on her back, and the right leg was marked "no," the report said. While the physician scrubbed, the patient was turned on her stomach, but the physician returned to the same side of the table, according to the report. He did not realize that the patient’s legs had changed positions when she was flipped over, and he made an incision on the wrong side, the report said. When he told the operating staff that the tendon looked fine, a nurse checked records and alerted the surgeon to his mistake. The lawsuit alleges that the surgeon damaged the good leg. This surgeon previously had been identified as a member of a surgical team that experienced a wrong-site operation.2
The "takeaway point" is that this institution did not mark the site they were going to cut, Hugenberg says.
"Their policy was to mark where you don’t cut with No,’" she says. "That’s not recommended to do because of issues just like this." In this case, there was no visual cue to tell the surgeon he was operating on the wrong area, she points out.
The Joint Commission protocol says the person performing the procedure should do the site marking on or near the operative site, and make the mark unambiguous (such as "yes" or initials). "You mark the site where you will be cutting so you know where you need to be," Hugenberg says. "The ink should draw you to the site."
There was initial resistance to this direction from surgeons who didn’t want ink on the site where they’ll be doing surgery, Hugenberg says. Those who resisted wanted to mark the other side, she says. "But as you can see, it can be contributory to errors being made," Hugenberg says.
When it isn’t feasible for the person performing the procedure to mark the site, another member of the surgical team who is fully informed about the patient and the intended procedure must make the mark, according to the Joint Commission.3 That person can include the pre-op RN, if allowed by state law and regulations, the organization says. The Joint Commission doesn’t recommend that the patient mark his/her own surgical site.
As a backup, checklists can be helpful to use before patients go into the OR, Hugenberg suggests. They can address areas such as site marking and team members being in agreement about the correct site, patient, and procedure. Also sources advise a final time out in the OR just before the case begins where everyone agrees that you have the right patient, correct procedure, and correct surgical site.
Most errors involving the wrong site, patient, or procedure are due to system problems, says David Wong, MD, MSc, FRCS, chair of the Patient Safety Committee of the American Academy of Orthopaedic Surgeons in Chicago.
Sometimes staff who work in outpatient surgery claim that they don’t have time to mark the site between cases, Wong says. "In that circumstance, we’ve encouraged people, in their pre-op visit in the physician’s office, where they’re signing consent, to do the site marking there in indelible ink that will last until the day of surgery," he says. "There are system things to put in place to address areas that are different."
• Physician performs surgery on healthy eye; $1 million verdict.
April Y. Bourne v. Michael B. Rivers, MD, et al serves as an example of how many factors can contribute to a wrong-site surgery case, Hugenberg says. A woman was to have surgery on her right eye. Her chart was confused with that of an older woman also scheduled to have surgery that day, but on her left eye. The surgeon noticed the discrepancy and attempted to ask the patient about it, but she was too sedated. The surgeon then changed the consent form to read "left."
"He overruled other staff who were trying to explore the situation, and apparently he didn’t re-examine the eye," says Hugenberg, who says the physical characteristics of the eye should have indicated which one was the correct one.
The lesson? "If there appears to be discrepancy, don’t pass instruments until it’s verified," says Hugenberg. "That didn’t happen here."
References
- Otto MA. Violations discovered at Puyallup hospital. The News Tribute. Accessed at www.thenewstribune.com/health/v-lite/story/4864769p-4464201c.html.
- Liberto J. Suit says doctor botched surgery. St. Petersburg Times, April 21, 2003:1.
- Joint Commission on Accreditation of Healthcare Organizations. Frequently Asked Questions about the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. Accessed at: www.jcaho.org/accredited+organizations/patient+safety/universal+protocol/faq_up.htm#12.
Resource
To see a free copy of the protocol, go to www.jcaho.org. Under "Top Spots," click on "Universal Protocol."
A wrong-site, wrong-procedure, and wrong-person universal protocol has been required by the Joint Commission on Accreditation of Healthcare Organizations since July 2004 and supported by multiple national organizations, but adverse events continue.Subscribe Now for Access
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