January 2022 • Volume 16, No. 1
From the Editor
As this issue goes to press, COVID-19 infection rates appear to be receding in many parts of the U.S., although hospitalization rates are expected to remain high for a while. Yes, we’re all wary of the constant barrage of coronavirus statistics in the news and what they may or may not mean, but if there is even a glimmer of hope for a less-infectious future in the near term, I’ll take it.
In this issue we take a look at wrong-site surgeries. The fact that this problem is relatively uncommon is one of the reasons it doesn’t get focused upon very often. But even though the Joint Commission’s Universal Protocol requesting time-outs before surgical procedures has been in use for nearly 20 years, a wrong-site surgery is estimated to happen once in every 100,000 surgeries, which translates to more than 100 times per year in the U.S. This includes everything from the wrong hip replaced or the wrong kidney removed to the wrong eye treated or the wrong spinal level operated on. We’ll look at some current coverage about why these errors are still happening and ways to prevent them.
Our Graduate in the Spotlight is Christine “Nicky” Hurry, BSN, CNOR, of La Prata, MD.
Scroll down for jobs we’ve collected for you and NIFA’s favorite links.
Finally, in these jangled times—hang in there.
Julie Lancaster, Editor
Current Efforts Toward Eliminating Wrong-site Surgeries
In 1998, the American Academy of Orthopaedic Surgeons launched a “Sign your Site” campaign, asking surgeons to mark and sign the correct site on a patient before surgery.
That approach was incorporated in 2004 into a more detailed procedure: the Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. The Universal Protocol asks surgical teams to follow a checklist that includes a pre-procedure verification process, the marking of the site, and a time-out, to confirm patient identity, correct site, and the procedure to be done, to be conducted by the surgical team immediately before the procedure.
These practices helped put a dent in the number of wrong-site surgeries, but did not stop them. In 2009, the Joint Commission engaged a group of hospitals and ambulatory surgery centers to conduct root-cause analyses of wrong-site surgeries and near misses, then used the insights gained to recommend procedural changes in a variety of areas. Those were published in a 2014 report, Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project.
MDs Doing Wrong-site Surgery: Why Is It Still Happening?
In a recent Medscape article, Leigh Page discusses wrong-site surgeries and malpractice repercussions. Did you know that two-thirds of surgeons who perform wrong-site surgeries are experienced surgeons in their 40s and 50s, not beginners? And it’s not just surgeons; other OR team members can make these mistakes. Many people have difficulty distinguishing right from left, especially when the patient is turned from supine to prone position. Some surgical team members are resistant to checklists and/or don’t pay attention during time-outs; as a remedy, some institutions are filming time-outs and grading OR teams on compliance. Read more . . .
Surgeons Sometimes Operate on the Wrong Body Part.
There’s an Easy Fix.
David L. Perlow, a board-certified urologist, writing in the Washington Post, makes a strong case for surgical teams to incorporate the practice of wrong-site labeling (labeling the opposite organ or body part with “no” or “wrong”) into their procedures whenever there is a risk of right/left confusion. Read more . . .
“It is uncommon for the root cause of preventable adverse events to be attributable to an individual’s lack of clinical competence of training, impairment, or lack of concern,” writes William H. Greene, MD, FIDSA, in the AORN Journal. “The problem often lies within a system of processes or personnel interactions that create opportunities for error.” The article explores best practices in redesigning processes and systems for behavioral change. Read more . . .