Wrong-site, Wrong-patient, Wrong-procedure

REFERENCES

• Gehrke, S. (2017, July 24). Right-Patient, Right-Site, and Right-Procedure Surgery. Retrieved from https://pacificmedicaltraining.com/2017/07/24/right-patient-right-site-right-procedure-surgery.html

• Hanchanale, V., Rao, A. R., Motiwala, H., & Karim, O. M. (2014). Wrong site surgery! How can we stop it?. Urology annals, 6(1), 57-62. Retreieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963345/

• Hempel S, Maggard-Gibbons M, Nguyen DK, et al. (2015, August). Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires : A Systematic Review of Surgical Never Events. JAMA Surg. 2015;150(8):796–805. doi:10.1001/jamasurg.2015.0301

• Kozusko, S. D., Elkwood, L., Gaynor, D., & Chagares, S. A. (2016). An innovative approach to the surgical time out: A patient-focused model. AORN Journal, 103(6), 617-622. Retrieved from: doi:http://dx-doi-org.madonnaezp.liblime.com/10.1016/j.aorn.2016.04.001

• Neily, J., Soncrant, C., Mills, P. D., Paull, D. E., Mazzia, L., Young-Xu, Y., Nylander, W., Lynn, M. M. Gunnar, W. (2018). Assessment of Incorrect Surgical Procedures Within and Outside the Operating Room: A Follow-up Study From US Veterans Health Administration Medical Centers. JAMA network open, 1(7), e185147. doi:10.1001/amanetworkopen.2018.5147

• Parks, S., (2015, May). "Reducing the Risks of Wrong Site Surgery Using the Joint Commission’s Targeted Solutions Tool for Safe Surgery". Doctoral Projects. 3. Retrieved from https://aquila.usm.edu/cgi/viewcontent.cgi?referer=https://scholar.google.com/&httpsredir=1&article=1003&context=dnp_capstone

Appraisal of Evidence / Appendix G

• The Joint Commission. (2018, January 23). Summary Data of Sentinel Events Reviewed by The Joint Commission. Retrieved from https://www.jointcommission.org/assets/1/18/Summary_4Q_2017.pdf

• Use the Joint Commissions Targeted Solutions Tool for Safe Surgery.

• Use the World Health Organizations Surgical Safety Checklist.

• Improve communication.

• Pay attention in 'time-outs'.

• Involve the patient and their family/caregiver.

Appendix G Link: https://docs.google.com/document/d/17_t44uUZqD-UbbUKQwlK0PAbZY8pzjsQ9klQVtSL2X8/edit?usp=sharing

How Can We Stop It? Cont.

How Can We Stop It?

• Use the Joint Commission Targeted Solutions Tool (TST) for Safe Surgery (Parks, 2015).

• 50 cases were analyzed; each operation was performed on the kidney, ureter, and the testis (Hanchanale et al., 2014).

• A study conducted across 6 months with a convenience sample of 47 surgical staff including RNs, surgical technicians, CRNAs, anesthesiologists and surgeons utilized the TST program (Parks, 2015).

• RESULTS: After implementing the TST tool, the risk of WSS was reduced from 16% to 9% in surgical booking, 86% to 53% in pre-op/holding, and 73% to 25% in the OR (Parks, 2015).

• It was found that a major cause of wrong side surgery is that the side of surgery is not always mentioned in the surgical boarding, surgical schedule, or consent form (Hanchanale et al., 2014).
• It is the surgeons responsibility to document what side they are working on in everything that is written whenever bilateral organs are involved.
• Imaging should also be verified for the correct patient and site (Hanchanale et al., 2014).

Parks, S., (2015, May). "Reducing the Risks of Wrong Site Surgery Using the Joint Commission’s Targeted Solutions Tool for Safe

Surgery". Doctoral Projects. 3. Retrieved from https://aquila.usm.edu/cgi/viewcontent.cgi?referer=https://scholar.google.com/&httpsredir=1&article=1003&context=dnp_capstone

Hanchanale, V., Rao, A. R., Motiwala, H., & Karim, O. M. (2014). Wrong site surgery! How can we stop it?. Urology annals, 6(1), 57-62. Retreieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963345/

Wrong-site, Wrong-patient,

Wrong-procedure: From Roots

to Results

How can we stop it?

• It is the physicians responsibility to mention if there are bilateral organs involved.

• The surgeon site marking should be visible and verified by all members of the surgical before the patient is prepped for the procedure.

• The surgeon should mark the site with their initials to verify the correct side.

How Stop It

• The surgeon should verify the correct side is listed on the consent and imaging.

• Time out should be conducted and the site, side, and procedure should be verified again before the procedure starts

How Can We Stop It

Bingham, S., Walsh, K., & Ford, K. (2018). Reshaping perioperative nursing practice to get the job done: A constructivist grounded theory study. Acorn, 31(1), 19-29. Retrieved from http://madonnaezp.liblime.com/login?url=https://search-proquest-com.madonnaezp.liblime.com:2443/docview/2069496144?accountid=27927

Figure 1: WHO Surgical Safety Checklist (Hanchanale et al., 2014)

Hanchanale, V., Rao, A. R., Motiwala, H., & Karim, O. M. (2014). Wrong site surgery! How can we stop it?. Urology annals, 6(1), 57-62. Retreieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963345/

How Can We Stop It? Cont.

Survey / What can we do?

• It has been increasingly recognized that the involvement of the patient in marking the site of surgery can decrease the incidence of wrong-patient, wrong-site, and wrong-operations being performed.

• Of 275 respondents, 38% reported experiencing uncertainty of patient identity, 81% experienced uncertainty about surgical site, and 60% experienced uncertainty about the correct procedure (Kozusko et al., 2016).
• One study created a "time out" that involves participation from the patient, the patient’s family members or caregivers.
• Since the inception of the created postoperative time out in June 2014, the surgical team has performed 988 procedures (Kozusko et al., 2016).

• Patients should also make sure the correct site is listed on the consent form (Hanchanale et al., 2014).

Universal Protocol for Wrong Side Surgery

Hanchanale, V., Rao, A. R., Motiwala, H., & Karim, O. M. (2014). Wrong site surgery! How can we stop it?. Urology annals, 6(1), 57-62. Retreieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963345/

• RESULTS: After implementing the total surgical checklist, there have been zero discrepancies between team members and zero wrong-site, wrong-side, or wrong-patient surgeries (Kozusko et al., 2016)!

KOZUSKO, S. MD, MEd; LILY ELKWOOD; DIANE GAYNOR, RN;STEPHEN A. CHAGARES, MD, FACS. (2016) June, Vol. 103, No. 6. Retrieve from:AORN J 103 (June 2016) 617-622. ª AORN, Inc, 2016. http://dx.doi.org/10.1016/j.aorn.2016.04.001K

• The Joint Commission developed the Universal Protocol to guide surgical team members in preventing wrong-site,wrong-procedure, and wrong-patient surgery.
• The Universal Protocol involves preprocedure verification, marking of the

surgical site, and performance of a time out

before surgery.

• Each surgical team member, including the surgeon, anesthesia care provider, RN circulate, and surgical technologist or

scrub person, has a role.

By: Jessica Elston, Killian Moore,

Shonya Stenson, and Holly Fenner

Madonna University ABSN Program

Figure 2: Strategies to Prevent WSS (Kozusko et al., 2016)

Kozusko, S. D., Elkwood, L., Gaynor, D., & Chagares, S. A. (2016). An innovative approach to the surgical time out: A patient-focused model. AORN Journal, 103(6), 617-622. Retrieved from: doi:http://dx-doi-org.madonnaezp.liblime.com/10.1016/j.aorn.2016.04.001

Wrong-Site Surgery: Causes

- One study that systematically reviewed such events noted that lack of proper communication was the root cause for wrong-site surgery, occurring as often

as 1 event per 100,000 surgeries (Hempel et al., 2015)

- Another study concluded that 28.4% of wrong-site cases resulted from issues performing comprehensive time-out procedures (Neily et al., 2018).

-

Hempel S, Maggard-Gibbons M, Nguyen DK, et al. (2015, August). Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires : A Systematic Review of Surgical Never Events. JAMA Surg. 2015;150(8):796–805. doi:10.1001/jamasurg.2015.0301

Neily, J., Soncrant, C., Mills, P. D., Paull, D. E., Mazzia, L., Young-Xu, Y., Nylander, W.,

Lynn, M. M., … Gunnar, W. (2018). Assessment of Incorrect Surgical Procedures

Within and Outside the Operating Room: A Follow-up Study From US Veterans

Health Administration Medical Centers. JAMA network open, 1(7), e185147.

doi:10.1001/amanetworkopen.2018.5147

PICO Question

LINK TO SPEAKER NOTES:

Why is this important?

Does failing to verify correct site, patient, and procedure increase the risk of wrong-site, wrong-patient, wrong-procedure events occurring, compared to verifying this information prior to surgery in the perioperative unit?

• According to The Joint Commission’s statistics on sentinel events, there were 95 voluntarily reported wrong-patient, wrong-site, wrong procedure events that occurred in 2018 (The Joint Commission, 2018).

• These "wrong-site, wrong-procedure, wrong-patient errors" (WSPEs) are rightly termed never events. These types of avoidable errors should never occur and indicate serious underlying safety problems.

The Joint Commission. (2018, January 23). Summary Data of Sentinel Events Reviewed by The Joint Commission. Retrieved from https://www.jointcommission.org/assets/1/18/Summary_4Q_2017.pdf

Why is this important? Cont.

https://docs.google.com/document/d/1dThodYK3_dWMhk5NRDaJ4CF4g8Zo59o5bzpAti0_hpk/edit?usp=sharing

• Wrong-site surgery was the third most reported sentinel event in 2018, following retained surgical items and falls, out of the 30 types found (The Joint Commission, 2018).

• Since 2015: 428 falls, 484 unintended retention of a foreign body, 440 wrong-site surgeries (The Joint Commission, 2018).

• In 1999, the Institute of Medicine called for each state to implement an adverse event reporting system. As of January 2015, 28 confirmed that they have a system in place and 23 verified that they do not. (Gehrke, 2017)

• Starting February 2009, the Centers for Medicare and Medicaid Services (CMS) no longer pays for additional costs accrued by preventable errors, including WSPEs (Gehrke, 2017).

Gehrke, S. (2017, July 24). Right-Patient, Right-Site, and Right-Procedure Surgery. Retrieved from https://pacificmedicaltraining.com/2017/07/24/right-patient-right-site-right-procedure-surgery.html

The Joint Commission. (2018, January 23). Summary Data of Sentinel Events Reviewed by The Joint Commission. Retrieved from https://www.jointcommission.org/assets/1/18/Summary_4Q_2017.pdf