Download a PDF of the Current Issue 2015 Volume 12 Number 3 July- September

Critical Processes for Preventing Wrong Site Surgery

Joseph J. Tepas, III, MD
3-1-1 Modern surgical practice is based on a growing knowledge of the biology of disease and on the continued evolution of sophisticated operative techniques. The hectic pace of healthcare attendant to these advances has exacted a significant toll on the precious time the surgeon is able to spend establishing a strong bond of trust that is the essential component of any physician-patient relationship. This limitation has become a prescription for disaster, setting the stage for a harried surgeon to inadvertently operate on the wrong patient, wrong organ, or wrong side. How can something so simple and intuitive as operating on the right part of the right patient be such a common cause for preventable catastrophe? The answer lies in process. Between the art and science of modern medicine lies order and discipline. Effective medical care requires that all providers have the discipline to follow an organized process of care. This is especially so for prevention of wrong site surgery. Because medical care is a human endeavor, it is susceptible to all of the failings of uncoordinated human effort.  Process is the pillar of patient safety that assures that the quintessential example of preventable error has no chance of occurring.   A recent survey of a network of 60 hospitals focused on perception of patient safety as assessed by the people who worked in them.  Surgeons, anesthesiologists, operating room technicians, and nurses had essentially the same level of confidence regardless of institution.  The extent of this confidence varied among institutions. What was perceived as a problem by one component of the operating room team was similarly perceived by all others.   The process of human endeavor that should control or, more significantly, prevent wrong site surgery focuses on three issues.  First is the patient’s ability to identify the appropriate side or site of operative intervention and reasons for the procedure. Second is the actual procedure to be performed.   This includes the personnel who will be performing the surgery and identifying, verifying, and marking the correct anatomic location where it will be performed.  Finally, there is the global issue of coordination and communication among patient, provider, administrator, and everyone else who is responsible for accumulation of specific information regarding the patient and the surgical procedure.   Patient-related issues can be problematic. Patients are sometimes forgetful and often have pre-existing problems that diminish their ability to remember discussion of the operative plan.  Because there is usually a delay between initial surgical evaluation and the performance of the procedure, marking the site at the time of initial office encounter is impractical.   What is of value, however, is the production of a “token.” This can be as simple as a 3”x5” index card on which the patient’s operative site is described in simple English. Both the patient and the physician sign and date the card. The card stays in the surgeon’s possession until the date of surgery, at which time it is presented to the patient and/or family to verify the intended procedure. Such a system is simple, reproducible, and protects individuals most at risk for wrong site surgery.  Both patient and provider have a strong incentive to assure that the token is provided on the day of surgery.  This system can be enhanced even further into a “no ticket, no laundry” policy, in which the absence of the token card signed by the appropriate personnel prohibits entry into the operating room.   Patient anatomy represents a different level of challenge. The obvious laterality of a hernia or lesion that is palpable or visible is relatively easy to identify and to confirm preoperatively with the surgeon’s initials. Of greater concern are the internal lesions, such as spinal cord pathology or other anatomic anomalies, that may not be apparent once operative exposure has begun. The best method to avoid this particular problem is to assure that the appropriate imaging studies that define the lesion to be addressed are available in the operating room with the patient. Moreover, many modern operating rooms now have access to portable CT scans or fluoroscopic C-arms that should be available 24 hours a day, 7 days a week should the surgeon need additional imaging to confirm that the level of operative intervention or location of operative field is as planned in the preoperative assessment.   The final component of process is the actual interaction of the individuals who represent the medical management team.  When evaluating the survey mentioned above and addressing specifically the issue of wrong site surgery, the three most common contributing factors were inadequate communication among the surgical team members, followed then by inadequate training of personnel, and lack of availability of patient information. The token system discussed above will certainly help with the information system.  One of the major improvements in patient safety that has evolved over the past few years has been the insistence that all members of the operative team responsible for providing operative surgical care function as a team. This requires that they know each other, communicate well with each other, train together, and are all apprised of the operative plan.   The traditional “time out” is an essential adjunct that mandates that all members of the team confirm the purpose of being there before the surgeon’s knife touches the patient’s skin. Because many hospital operating room staff are still not effectively organized as teams, the real value of a “time out” can be undermined by the constant parade of personnel going in and out of the operating room as the patient’s anesthetic is induced and the procedure begun. Many hospitals have begun to augment the “time out” to an actual briefing and debriefing where, prior to entry into the operating room, the entire operating team including anesthesiologists, technologists, and nurses meet at the patient’s bedside with the patient awake to assure one another that the plans for the operative intervention have been appropriately defined and that all members know exactly what is intended.  This may represent a significant investment in time and motion; however, the return on the investment and the avoidance of even one errant operative misadventure is well worth the effort.   Wrong site surgery continues to be a problem and a threat to patient safety in American hospitals. It represents the absolute classic opportunity for those who work in these facilities, and whose commitment to good healthcare is manifest with every day’s work, to organize very simple systems of communication and coordination that will assure that this preventable disaster is, in fact, completely eliminated.