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Eliminating wrong-site, wrong-side procedures
by: LAWRENCE M. SHUER
Imagine you are a patient entering a hospital to undergo a surgical procedure. One of the last things you would expect is that the physicians and nurses could make an error and perform the procedure on the wrong side of your body or at the wrong site. Worse yet, how would you like to awaken from anesthesia and learn that the physicians had performed the wrong procedure on you, mistaking you for another patient?
"That sort of problem can't happen here," you say. Unfortunately, over the past seven years we have experienced some of these types of errors, along with some "near-misses."
Eliminating wrong-site, wrong-side surgeries has been a focus particularly for the American Academy of Orthopedic Surgeons, which developed the "Sign Your Site" initiative in 1997 in an effort to stop preventable errors in the operating room. The academy recommended that having the surgeon mark the surgical site on the awake and alert patient immediately before surgery would help stop this error from occurring.
Other key medical societies and organizations have become involved in the issue as well. The American College of Surgeons last fall issued recommendations that built upon the AAOS approach. And the Joint Commission on Accreditation of Healthcare Organizations has highlighted the problem in its 2003 National Patient Safety Goals, which apply to all of its accredited organizations. Two of the 2003 goals are improving the accuracy of patient identification and eliminating wrong-site, wrong-patient, wrong-procedure surgery.
In May, the joint commission hosted a summit aimed at reaching consensus on a universal protocol for preventing wrong-site, wrong-procedure and wrong-patient surgery. The summit was attended by representatives of most of the major medical organizations, including the American Medical Association, American Hospital Association, American College of Surgeons and the American College of Physicians. The key recommendations that emerged from the summit included the following:
Verification, site-marking and "time-out" procedures should be as consistent
as possible throughout the organization, and should be carried out not
only in the OR but also in other locations where invasive procedures are
performed.
The clinician performing the procedure should do the site marking. If
this is a resident, the surgeon-of-record should provide confirmation.
Here at Stanford, we have implemented a "time-out" procedure in the operating rooms over the past year. This means there must be a pause before starting the procedure, during which everyone in the room - the surgeon, anesthesiologist, nurses and any other staff present - agree upon the procedure, the side and site on which the surgery is to be performed. Given that this protocol has proven very effective, and given the increased emphasis on preventing wrong-site surgery, we are now expanding the "time-out" to other sites where procedures are performed, such as in the cath lab, endoscopy suites and the radiology department.
To ensure compliance with this protocol, we will require that the surgeon or other clinician performing the procedure mark the side or site before the patient receives any sedation or anesthesia. This will allow for a safety check whereby the patient has the opportunity to verify the correct site and procedure. As part of this effort, we have developed a "boarding pass" that is essentially a checklist to make sure all steps have been taken to properly identify the patient and surgical site before procedures begin.
I recognize that implementing this new protocol will require a change in our culture, as it is different from the way we have done things over the years. I hope all of our physicians recognize that these steps are being taken in the interest of improving patient safety - a goal all of us should endorse completely.
If you have questions or comments, please contact me at lshuer@stanford.edu
