Wrong-Site Surgeries Can Be Prevented with Proper Protocols
Wrong-site surgeries declined in Pennsylvania in 2007, and those that did occur could have been prevented with proper protocols, according to the Pennsylvania Patient Safety Authority (PSA).
During visits to six volunteer hospitals, the PSA found that four hospitals reported more than one wrong-site surgery in a two and a half year period, while the other two hospitals didn’t report any wrong-site surgeries.
Proper protocols should include asking active questions to verify patient information. For example, ask, “What arm are we operating on?” and not “We’re operating on your left arm, right?”
PSA offers some tips to ensure proper marking of the surgical site:
- Reconcile all important information including history and physical, consent, OR schedule, and diagnostic studies.
- Involve the patient or surrogate in identifying the site before sedation.
- Use a mark consistent with the facility’s protocol, but never use an ‘X.’
- Make sure the mark will be visible up to and including the final time out.
- Perform regional blocks only after the site has been markedMake sure members of the OR team are empowered to voice concerns and that each concern is addressed.
For more information on appropriate site markings and the complete findings of the PSA’s facility visits, read the December 2007 Patient Safety Advisory.
Last Updated: 1/16/2008