Preventing Wrong-site Surgery and “Never Events” – 6 Effective Ways

Wrong-site surgery events can have devastating consequences for patients, as well as for healthcare providers and facilities. These “never events” are preventable, which adds to their severity.

While the pressures of emergent situations and overburdened staff are often to blame, there are ways that medical professionals can make sure never events truly never happen.

This article reviews six main causes and risk factors leading to wrong-site surgeries and the multiple, complementary strategies for addressing them.

What is wrong-site surgery?

Wrong-site surgery refers to surgery on the wrong site, wrong side, wrong procedure, wrong implant, or wrong patient.

Wrong-site surgeries are considered preventable and aren’t seen as acceptable risks of surgery. As such, they’re termed “never events,” or events that should never occur. Let’s right these wrongs…

1. Manage your surgical scheduling comprehensively

The surgical scheduling service is charged with patient management. This system is responsible for coordinating the scheduling of surgical procedures in a healthcare facility while considering individual patient’s medical needs, preferences, and availability.

More importantly, the scheduling process is the initial point for preoperative patient verification. It offers the first chance to verify patients and their needs accurately. Inconsistencies in this process have contributed to the risk of wrong-site surgery. Factors like verbal requests, absence and inaccuracy of documents/orders, illegible handwriting, and use of unapproved abbreviations can all contribute to the risk of wrong-site surgery during this process.

Several recommendations have been proposed by the American Hospital Association (AHA) and the Joint Commission Center (JCAHO) for minimizing errors during this step of the preoperative verification process. These recommendations include:

• Confirm the presence and accuracy of all documents, such as booking documents, procedure orders, and patient charts, during scheduling.
• Identify inconsistencies requiring reconciliation.
• Carry out scheduling based only on written orders.
• Use clear, legible writing without cross-outs and unapproved abbreviations for all written documents.
• In case of information changes, verify that updated documents replace existing information.

2. Avoid errors in preoperative holding

The preoperative holding area is a designated space where patients are prepared for surgery. The preoperative holding of patients also offers a second opportunity at preoperative patient verification. During this time, the surgical team reviews all relevant documentation (history and physical, consent, etc.), relevant images, and the requirement for implants and special equipment.

Inadequate or cursory verification and absent information or inconsistencies in patient records during the pre-operative holding assessment are further factors that increase the risk of wrong-site surgery.

Similarly, AHA and JCAHO have made recommendations on how to avoid errors leading to wrong-site surgery during this stage of the preoperative verification process. These recommendations include:

• Ensuring relevant documents and studies are available, labeled, and matched to the patient’s identifiers prior to surgery.
• Ensuring review of all pertinent documents and studies and verifying their consistency with the patient’s expectations and the surgical team’s understanding of the intended patient, procedure, and site.
• Furthermore, patients or their legally designated proxies should be aware of and involved in these processes.

3. Mark the surgical site correctly

Surgical site marking is a vital process for the surgical team. These markings let them unambiguously identify the correct surgical site on a patient’s body. This ensures that the intended procedure is performed on the right side, part, and level of the body. It’s the single most crucial step in promoting patient safety by preventing wrong-site surgeries.

Wrong-site surgeries are frequently a complication of errors made during the preoperative surgical site marking process. These errors can have catastrophic consequences for patients and have a detrimental impact on the surgical team.

The Universal Protocol for Preventing Wrong-site, Wrong Procedure, and Wrong Person Surgery published by the Joint Commission and World Health Organization (WHO) Safer Surgery Checklist offers extensive preoperative surgical site marking recommendations.

These recommended steps are aimed at standardizing the process, thereby minimizing errors, and significantly decreasing the incidence of wrong-site surgeries. The following are the recommendations offered by the Universal Protocol and the WHO Safer Surgery checklist:

• Surgical site marking should be carried out for all procedures involving right/left distinction, multiple structures (i.e., fingers and toes), or multiple levels (i.e., spinal procedures).
• Only the incision or insertion site should be marked. Nonoperative site or sites shouldn’t be marked as this can lead to possible confusion.
• The markings should be clear and unambiguous. Use of the operating surgeon’s initials or lines representing proposed incisions or insertion sites is recommended.
• Markings should be made in such a way that they remain visible after the patient is draped.
• Markings should be made with high-visibility ink and resistant to smudging or fading during the skin preparation process.
• The sole use of adhesive site markers should be avoided.
• The surgeon performing the procedure should also perform the surgical site marking.
• The method and type of surgical site marking should follow a consistent protocol used by all facility staff.
• If possible, the patient, who has the greatest stake in avoiding errors, should be awake and aware during the surgical marking process and should be actively involved.

4. Have an effective “time out” before surgery

A surgical “time out” is a preoperative critical safety procedure conducted in the operating room just before the start of a surgical procedure. This brief pause brings together the entire surgical team, including surgeons, anesthesiologists, nurses, and other relevant personnel in the room, and promotes active communication among them. The purpose of the time out is to afford a final opportunity to double-check and confirm essential details about the patient, procedure, and surgical site and ensure that everyone on the surgical team is on the same page.

Alternatively, the preoperative time-out process is also the last place where errors leading to wrong-site surgery may occur. Errors in the time-out process, such as miscommunication among team members, hesitation in speaking up by team members, inaccurate or missing patient information, distractions or interruptions, or rushing through the time-out process, can all increase the risk of wrong-site injury.

Recommendations that help minimize errors during the time out include:

• The time-out should take place in the location where the procedure will be done and should occur just before starting the procedure.
• A designated team member should consistently initiate the time out.
• The time-out should be conducted in a “fail-safe” mode, meaning the procedure won’t start until all questions and concerns are resolved.
• It should involve the entire operative team, use active communication, and be briefly documented.
• The “time out” should verify and ensure that the entire surgical team agrees to all the following before the incision is made:
  • Correct identity of the patient

• Correct surgical site

• If applicable, correct level, side, or structure

• Correct procedure to be performed

• Correct patient position

• Availability of correct implants and any special equipment or requirements

5. Eliminate environmental distractions

Performing surgery demands a heightened level of concentration and fine-motor skills to achieve precision and coordination of decision and hand movements to manipulate surgical instruments. Unfortunately, the OR environment often isn’t as calm and organized as one would expect. Studies have recognized environmental factors such as distractions, noise, clutter, ergonomics, and interruptions as significant contributors to the risk of wrong-site surgeries and the breakdown of the Universal Protocol in general.

Time constraints, heavy caseloads, and working in emergency situations further external environmental factors that have been shown to increase the likelihood of surgical errors such as wrong-site surgeries.

There have been numerous attempts at creating a distraction-free environment in the OR. These attempts have employed implementing standardized protocol, designating special team members responsible for minimizing distractions, and limiting the use of electronic devices. For example, the WHO Safer Surgery Checklist recommends a “sign-out procedure,” allowing the entire team one last opportunity to regain focus on the stated facts of the procedure before concluding surgery. Although this may not always help prevent wrong-site surgery, it can promote its early detection and perhaps prevent its undesirable consequences.

6. Be careful of human error

Wrong-site surgeries, and medical errors in general, can be attributed to human factors. The human factor is an important risk for wrong-site surgery. For example, fatigue and stress are known to predispose to increased frequency of human error in surgery.

Finally, patients themselves can elevate the risk of wrong-site surgery. Research indicates that patient-related factors such as behavioral issues, language barriers, non-compliance, lack of understanding, fear, and the severity of their medical condition can heighten the likelihood of medical errors. Unfortunately, these factors are either inherent or deeply ingrained in medical practice and difficult to eliminate entirely. This is why systems-based prevention methods, as mentioned above, are employed instead. These approaches attempt to trap and manage inherent errors before they can cause harm to the patient.