Wrong Site Surgeries

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Wrong Site Surgeries

Wrong Site Surgeries Wrong site surgeries are very rare, but sometimes wrong site surgeries happen. The wrong site surgeries have damaging results for the patient and pose a huge safety problems within the organization. Usually communication breakdown is considered the main cause of wrong site surgeries in the surgical team. The Joint Commission 's universal protocol of "time out" is a very important and a helpful tool in preventing the wrong site surgeries, wrong person surgery, and wrong procedure. The factors causing the wrong site surgeries can be; • presumption of surgical team members that someone else has confirmed surgical site and procedure • surgeon failing to mark the site • placing the x-rays backward causing the laterality to reverse • Lack of communication between the surgeon and patient • In single encounter performing multiple procedures • Surgeries requiring patient to position in different angles on the OR bed • Failure of surgeon to include the patient and family members when identifying the correct site • Partial pre-operative assessment of the patient • Pressure to reduce the pre-operative preparation time The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has come up with the universal protocol, a very helpful tool in preventing wrong site surgeries. The universal protocol includes pre-procedure verification of the surgical site by the surgeon and marking the site, verification of the correct site by the anesthesia provider and the circulating nurse with patient or family member in case of minor or mental retarded patients. The purpose of the pre-procedure verification is to identify the patient, the procedure, site, availability of required x-rays, instruments, and implants. Any missing information or discrepancies can be addressed before the patient could go to the



References: Atkinson, R., & Royle, J. (2007, October). Correct patient, correct side, and correct site surgery. ANZ Journal of Surgery, 77(10), 809-810. Retrieved from http://web.ebscohost.com.ezproxy.apollolibrary.com/ehost/pdfviewer/pdfviewer Makary, M. A., Mukherjee, A., & Sexton, B. J. (2007). Operating room briefing and wrong site surgery. Journal of American College of Surgery, 204, 236-243. Retrieved from http://www.psnet.ahrq.gov/resource.aspx?resourceID=4853 The Association of Perioperative Registered Nurses. Position statement on correct surgery site. AORN February 2001. Available at:http://www.aorn.org/PracticeResources/AORNPositionStatements/PositionCorrectSiteSurgery/. Accessed August 10, 2010. The Joint Commission on Accreditation of Healthcare Organizations. (2003, July 21). Universal protocol established for preventing wrong site, wrong procedure, wrong person surgery [news release comment]. Retrieved from http://web.ebscohost.com.ezprox..apollolibrary.com

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