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Wrong Site Surgery

There is a parallel between patient safety and aviation safety.

The airline industry has a prescribed checklist before a plane can even take off. There is a culture of safety in aviation that is lacking in healthcare and an absence of accountability when things go wrong.

The aviation industry implemented safety measures because pilots are responsible for the lives of their passengers. So, too, are doctors responsible for the lives of their patients.

So why doesn’t the healthcare industry do the same?

Most medical errors happen in the operating room where there is increased pressure to turn over operating rooms quickly; that’s how doctors get paid. The problem is that this model trumps patient safety, increasing the chance of error.

Wrong site surgery (WSS) is one such medical error. It is any surgery performed on the wrong body part, wrong side of the body, wrong patient, or at the wrong level of the correctly identified anatomical side. It is considered a Sentinel Event, also known as “Never Events” because they should never happen. Those are serious, largely preventable incidents that should not occur if the available preventative measures were implemented.

The U.S. Department of Health and Human Services estimates that these errors occur once in every 112,000 surgeries and at individual hospitals once in every 5 to 10 years.

Additionally, the Joint Commission, a non-profit organization who accredits the nation’s hospitals says that approximately 1, 102 wrong patient, wrong site, or wrong procedure surgeries occurred in a period of a decade. Using the aviation model, they created a universal protocol, a global checklist with safety guidelines including pre-operative verification of important details, marking of the surgery site, and a time-out to be done before, during, and after an operation. These steps have been proven to lower surgical mistakes significantly and save money.

1. Pre-operative: conducting a documented, independent verification and reconciliation of patient information that the surgical team members verify separately by repeating questions that require active responses from the patient. This includes his or her name, the procedure, and site location. It will also incorporate developing a protocol for marking the surgical site, and confirming the location of the opaque marker to confirm location of the specific surgical site.

2. Post-operative: Establishing a policy for the hospital staff responsible for cleaning the operating room between procedures, making them responsible for identifying, removing, and proper disposal of surgical materials to designated staff.

Preventing wrong site surgery involves changing the culture of the healthcare industry, and getting doctors, who tend to resist checklists, to follow standardized procedures and work in teams. Doctors who verify the site and procedure with patients before they are wheeled into the operating room are less likely to make a mistake, as are those who ask team members to speak up if they have concerns.

Wrong site surgery is inconceivable to people outside the healthcare industry but it occurs in hospitals nationwide. Consequences vary from having no long-lasting effects on the patient to those causing irreversible damage. Both can have a devastating effect on patients and their families.

As a result, hospitals are moving to improve transparency of information by implementing action goals aimed at identifying vulnerabilities and challenges and develop strategies for overcoming them.

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