Wednesday, February 10, 2010

How does Wrong Site Surgery Happen? Part 1

Everyone know someone who has had surgery. But did you know that breakdowns in the surgical care process can happen at many points? Procedures are in place to match the patient's arm band with verbally asking the patient what their birth date is to insure it is the correct patient. The surgeon marks the patient prior to arriving in the OR. OR staff is responsible to insure the appropriate consent form indicates the body part the surgeon has marked prior to induction of anesthesia. The area is then prepped and the surgeon's initials should still remain after preparation for surgery to indicate the site. At every point in the process there is a possibility of error.

The actions of the surgeon in the OR are a huge determinant of whether wrong site surgery occurs; surgeons have control of the actual incisions and procedures performed. Despite having all the right consent forms and procedures outlined, ultimately control lies in the hands of the surgeon. With that being said, incidence of wrong site surgery increases with transfer of patients from one surgeon to another as well as having multiple surgeons operating at one time.

The Joint Commission states the root cause analysis (RCA) of wrong site surgeries are that:
1. Time out procedures aren't performed
2. Not verifying consents or site markings
3. Inaccurate consents/diagnostic reports/images,
4. Patient's positioning can be determinants as well. Larger patients/obese patients make positioning of the equipment slightly different than what normally happens in the OR.

Related Articles:
Wrong Site Surgery is a Never Event
Despite efforts to avert - Wrong Site Surgery still occurs

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