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Ensuring correct site surgery.

Introduction

In the United States (US) the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) sentinel event reporting system has highlighted that wrong site surgery is the most frequent event reported to them. The numbers are going up not going down. Recently in the US a hospital was fined by its authority for its third case of wrong side craniotomy (Rhode Island Department of Health 2007, Smith 2007, ABC News 2007). There is beginning to be shift in culture, from one where this type of event is accepted as part of the normal events in hospital, with individual practitioners believing this will never happen to them, to one where wrong site surgery is seen as an event that should never happen and a punitive element is starting to emerge.

Is wrong site surgery that common?

It is difficult to measure. Traditional incident reporting systems are notorious for under-measurement of event rates. Research in the US has suggested that wrong site surgery happens every 5-10 years, or one in 112,994 cases (Kwaan et al 2006). These are actual incidents of wrong site surgery. However the number of near misses are much higher and even more difficult to measure. The Patient Safety Authority in Pennsylvania receive a report of wrong site surgery (either actual or prevented) every two days (Advisory 2007). From June 2004 to December 2006, 427 reports were submitted that reflected some aspect of wrong site surgery. More than 40% of these errors actually reached the patient, and nearly 20% actually involved completion of a wrong site procedure. Reports were submitted from about one of every three acute care hospitals.

[FIGURE 1 OMITTED]

The National Reporting and Learning System at the NPSA collates patient safety incidents reported in the NHS. Those incidents that could potentially relate to wrong site surgery are reviewed and the following themes have emerged (see Figure 1).

As you can see the most common problem reported to the NRLS is that the operating list identifies the operating site incorrectly, this could be that there is a minor error in the patient identification details. For example either something relatively minor such as the patient's age is incorrect, to a major error where the operation on the list is completely wrong. Since the introduction of the National Reporting and Learning System no reports suggest a patient has died. However, the types of incidents include inserting the wrong implant, making an incision at the wrong site, or transplanting a tendon on the wrong side. There are many more reports of anaesthetic blocks administered to the wrong site than wrong site surgery.

There are mechanisms to avoid wrong site surgery and promote safe care of the patient. Using the national guidance from the National Patient Safety Agency (NPSA) and the Royal College of Surgeons in England (RCS) will greatly reduce the chances of this type of event (NPSA 2005) (see Figure 2). The alert approaches the problem from two ways, marking patients and a checklist.

Standard preoperative marking

The alert recommends the patient should be marked using an indelible marker pen as close to the incision site as possible. The alert advises that the mark used is an arrow that remains visible after the positioning of theatre drapes. The NPSA and RCS also highlight that marking is particularly pertinent when surgery involves left or right side and multiple structures of levels, such as vertebrae or fingers and toes.

[FIGURE 2 OMITTED]

Verification of site of surgery

CHECK NUMBER ONE identifies the patient and cross-checks against their documentation, such as X-rays, before the surgical site is marked. This check is done either by the operating surgeon or a person who is going to be present at the time of surgery. It is up to individual organisations to identify what they consider to be reliable documentation.

CHECK NUMBER TWO double matches the patient's surgical mark against their documentation before the patient leaves the ward and ensures that the relevant images are going to be available at the next stage of their treatment. This check requires qualified ward staff, not unqualified staff, to sign off this requirement.

CHECK NUMBER THREE is in the anaesthetic room before anaesthesia. The mark is checked against the supporting documentation, and the availability of the correct implant (such as artificial joint) is confirmed. This check is performed by the operating team.

CHECK NUMBER FOUR Finally, having carried out all of these checks, the alert advises that a short pause is taken before continuing further with surgery. This allows for a verbal confirmation of patient, site and procedure. The operating team conducts a final verification of the correct patient, procedure, site and, as applicable, the implant. This involves the entire operating team in the 'time out' at the same time to actively confirm their understanding.

The future

Correct site surgery is not only high on the UK patient safety agenda, but it is a global issue. The World Health Organisation World Alliance for Patient Safety and the WHO Collaborating Centre for Patient Safety, have a 'High 5s' initiative as a mechanism to implement innovative, standardised operating protocols for five patient safety solutions over five years. One of the solution areas is the prevention of wrong site/wrong procedure/wrong person surgical errors (Figure 3).

Conclusion

Wrong site surgery is unacceptable. It is not the goal to reduce the numbers of incidents of wrong site surgery, this event should never happen. There is a national standardised way of marking and verifying the site of surgery. This practice is not optional. The Healthcare Standards in both England and Wales emphasize the need for safety and bodies such as the Healthcare Commission in England and Health Inspectorate Wales will check organisations are implementing this type of practice. This issue has international attention, and there will be worldwide interest in any incident of wrong site surgery. The NPSA will continue to explore how this incident can be avoided by understanding the root causes of these events.

When incidents get reported to the National Reporting and Learning System they will be followed up to identify if there is any further national learning required. Locally organisations and theatre teams can do so much to reduce the chances of this type of incident by questioning current practice--not just accepting that it won't happen because it hasn't happened yet; and by working as a team. It isn't just up to the surgeon and by being vigilant.

[FIGURE 3 OMITTED]

Every member of the surgical team has a clear role to play in the promotion of safe surgery. Correct site surgery is one type of error, but it has the potential to be one of the most devastating.

Provenance and Peer review: Commissioned by the Managing Editor; Peer reviewed.

Additional Learning Resources

Associated AfPP online modules: Back to basics All these modules will have Knowledge and Skills Framework dimensions and Notional Learning Hours attached. To complete this learning resource go to the AfPP website and enter the Online Learning site which is under the Career Development tab.

* Communication Skills

* Patient Care in the Operating Department

* Organisational Skills and Tools

* Health and Safety

* Liability and Accountability

* Care and Responsibility

* Preoperative Assessment

Reflective model

You will find this reflective model template and many others under the career development tab on the AfPP website.

Borton's (1970) framework guiding reflective activities

* Returning to the situation (What happened?)

* Understanding the context (So what did you learn?)

* Modifying future outcomes (Now what should I do in the future?)

[ILLUSTRATION OMITTED]

References

ABC News 2007 Hospital repeats wrong-sided brain surgery www.abcnews.go.com/Health/Story?id=3925810&pag e=1 [Accessed 14 February 2008]

Advisory Pennsylvania Patient Safety Authority 2007 Doing the 'right' things to correct wrong site surgery Patient Safety Advisory 4 (2) 29-45

Kwaan MR, Studdert DM, Zinner MJ, Gawande AA 2006 Incidence, patterns, and prevention of wrong-site surgery Archives of Surgery 141 (4) 353-357

National Patient Safety Agency 2005 Patient Safety Alert 6: Correct Site Surgery Available from: http://www.npsa.nhs.uk/patientsafety/alerts-and-directives/ alerts/correct-site-surgery [Accessed 14 February 2008]

Rhode Island Department of Health 2007 HEALTH Cites Deficiencies, Issues Compliance Order to Neurosurgery Department at Rhode Island Hospital Available from: http://www.health.ri.gov/ media/071126t.php [Accessed 14 February 2008]

Smith MR 2007 Mistakes lead to three wrong side brain surgeries at RI Hospital www.boston. com/news/education/higher/articles/2007/12/14/ mistakes_led_to_3_wrong_side_brain_surgeries_at_ri_h ospital [Accessed 14 February 2008]

Web links and key documents

Root causes for incidents

http://www.jointcommission.org/NR/rdonlyres/90B92 D9B-9D55-4469-94B1-DA64A8147F74/0/se_rc_wss .jpg [Accessed 14 February 2008]

Reporting rate US

http://www.jointcommission.org/NR/rdonlyres/6F942 88C-EC8E-4B95-91F6-0A1C96C09708/0/se_trends _wss_reported.gif [Accessed 14 February 2008]

Scotland case

http://www.gmc-uk.org/concerns/hearings_and_ decisions/ftp/20070613_ftp_panel_blanchard.asp [Accessed 14 February 2008]

Evaluation of alert

http://qshc.bmj.com/cgi/content/abstract/15/5/36 3 [Accessed 14 February 2008]

Rhode Island Case

http://www.projo.com/news/content/WRONG_Site_1 1-27-07_PB818Q7_v12.2704b40.html [Accessed 14 February 2008]

Task 1

It is the responsibility of the whole team to avoid wrong site surgery and ensure patients have the correct treatment. Reflect on your particular role in this. What is it that you contribute towards safe patient care; what drives that within your department?

Task 2

Notional Learning Hours 1 hour for your reflection.

Knowledge and Skills Dimension

Core: Health, safety and security Core: Service improvement Core: Quality

Health and well-being HWB6: Assessment and treatment planning

Level 1: Undertake tasks related to the assessment of physiological and psychological functioning.

Health and well-being HWB2: Assessment and care planning to meet people's health and well-being needs.

Level 3: Assess health and well-being needs and develop, monitor and review care plans to meet specific needs.

Task 2

Review: The policy you have in place. Is it clear what is expected of you? Discuss: Identify what barriers do you have in place to ensure the correct surgery is performed on the correct patient at the correct site.

Discuss these with a colleague. Can you identify where these can fail?

Notional Learning Hours 1 hour for your review and discussion.

Knowledge and Skills Dimension

Core: Health, safety and security Core: Service improvement Core: Quality

Task 3

How many patients are operated upon each year in the department, if you know how many then you can then work out the potential risk of how often wrong site surgery can happen within your department?

Notional Learning Hours 1 hour for your reflection.

Knowledge and Skills Dimension

Core: Health, safety and security Core: Service improvement Core: Quality

Task 4

Project:

Take a typical operating day with a mix of cases, for example a general surgery list in one theatre and orthopaedics in another. How many patients should have been marked compared to how many were marked? Do you regularly audit this practice? What are the results? Is the mark always visible after the patient has been draped and is it clear once the patient has been prepped with antiseptic solution?

1. Audit how many checks have been completed.

2. Observe how often check four takes place

3. Observe how many people enter the theatre after check four has taken place/or when the patient identity has been confirmed who take part in the surgery.

Notional Learning Hours 1 hour.

Knowledge and Skills Dimension

Core: Health, safety and security Core: Service improvement Core: Quality

Task 5

Discuss this fictional case study

An 85 year-old lady fourth on the list for a right phaco emulsification. The three patients before her are all listed for procedures on the left side. There had been difficulties all morning as the usual ODP was sick and so the list was delayed while obtaining a replacement. General staff shortages meant getting patients to theatre had been a problem due to a lack of porters. Half way through the morning there had been a phone call to reception to say the third patient wasn't feeling well and had decided not to have her operation. Mrs R was then sent for and the preoperative checklist indicated that the patient hadn't been marked, it wasn't this surgeon's usual practice to mark. There had been a delay in getting Mrs R to theatre because there were still portering problems so everyone was keen to get started so the list wouldn't over run. Mrs R was taken into the anaesthetic room and then transferred to the theatre and positioned on the table. The surgeon had gone off to make a phone call during the delay and rushed into theatre, briefly spoke to the patient and checked the notes, he went off to scrub. He came back into theatre and started to drape the patient. It was at this point that the ODP noticed that the surgeon was draping the right eye, and asked the scrub nurse to check that it was the correct eye. She quietly asked the surgeon and they checked the notes with the circulating nurse. It was confirmed that it was the right eye that required surgery, the ODP then pointed out to the surgeon and the anaesthetists that the regional block had been put into the left eye.

Discuss:

How do you think this has happened? What do you think are the barriers that failed? What could be done to stop it happening again?

Notional Learning Hours 1 hour for this discussion.

Knowledge and Skills Dimension

Core: Health, safety and security Core: Service improvement Core: Quality

Task 1

It is the responsibility of the whole team to avoid wrong site surgery and ensure patients have the correct treatment. Reflect on your particular role in this. What is it that you contribute towards safe patient care; what drives that within your department?

Task 2

Notional Learning Hours 1 hour for your reflection.

Knowledge and Skills Dimension

Core: Health, safety and security Core: Service improvement Core: Quality

Health and well-being HWB6: Assessment and treatment planning

Level 1: Undertake tasks related to the assessment of physiological and psychological functioning.

Health and well-being HWB2: Assessment and care planning to meet people's health and well-being needs.

Level 3: Assess health and well-being needs and develop, monitor and review care plans to meet specific needs.

Task 2

Review: The policy you have in place. Is it clear what is expected of you? Discuss: Identify what barriers do you have in place to ensure the correct surgery is performed on the correct patient at the correct site.

Discuss these with a colleague. Can you identify where these can fail?

Notional Learning Hours 1 hour for your review and discussion.

Knowledge and Skills Dimension

Core: Health, safety and security Core: Service improvement Core: Quality

Task 3

How many patients are operated upon each year in the department, if you know how many then you can then work out the potential risk of how often wrong site surgery can happen within your department?

Notional Learning Hours 1 hour for your reflection.

Knowledge and Skills Dimension

Core: Health, safety and security Core: Service improvement Core: Quality

Task 4

Project:

Take a typical operating day with a mix of cases, for example a general surgery list in one theatre and orthopaedics in another. How many patients should have been marked compared to how many were marked? Do you regularly audit this practice? What are the results? Is the mark always visible after the patient has been draped and is it clear once the patient has been prepped with antiseptic solution?

1. Audit how many checks have been completed.

2. Observe how often check four takes place

3. Observe how many people enter the theatre after check four has taken place/or when the patient identity has been confirmed who take part in the surgery.

Notional Learning Hours 1 hour.

Knowledge and Skills Dimension

Core: Health, safety and security Core: Service improvement Core: Quality

Task 5

Discuss this fictional case study

An 85 year-old lady fourth on the list for a right phaco emulsification. The three patients before her are all listed for procedures on the left side. There had been difficulties all morning as the usual ODP was sick and so the list was delayed while obtaining a replacement. General staff shortages meant getting patients to theatre had been a problem due to a lack of porters. Half way through the morning there had been a phone call to reception to say the third patient wasn't feeling well and had decided not to have her operation. Mrs R was then sent for and the preoperative checklist indicated that the patient hadn't been marked, it wasn't this surgeon's usual practice to mark. There had been a delay in getting Mrs R to theatre because there were still portering problems so everyone was keen to get started so the list wouldn't over run. Mrs R was taken into the anaesthetic room and then transferred to the theatre and positioned on the table. The surgeon had gone off to make a phone call during the delay and rushed into theatre, briefly spoke to the patient and checked the notes, he went off to scrub. He came back into theatre and started to drape the patient. It was at this point that the ODP noticed that the surgeon was draping the right eye, and asked the scrub nurse to check that it was the correct eye. She quietly asked the surgeon and they checked the notes with the circulating nurse. It was confirmed that it was the right eye that required surgery, the ODP then pointed out to the surgeon and the anaesthetists that the regional block had been put into the left eye.

Discuss:

How do you think this has happened? What do you think are the barriers that failed? What could be done to stop it happening again?

Notional Learning Hours 1 hour for this discussion.

Knowledge and Skills Dimension

Core: Health, safety and security Core: Service improvement Core: Quality

Peggy Edwards

MSc, RN, Dip Operating

Department Practice

Patient Safety Manager (Wales), National Patient Safety Agency

Correspondence address: National Patient Safety Agency, 4-8 Maple Street, London, England, W1T 5HD.
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Title Annotation:OPEN LEARNING ZONE
Author:Edwards, Peggy
Publication:Journal of Perioperative Practice
Geographic Code:1USA
Date:Apr 1, 2008
Words:3031
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