Taylor: According to the Joint Commission Center for Transforming
Healthcare, the incidence of wrong-site/wrong-procedure/wrong-pa-tient surgery may be as high as 40 times per week. Many experts
believe that the frequency of wrong-site surgery is not necessarily
increasing, rather the actual reporting of these events may be on the
rise. The increase in reporting of events may be the result of states
and organizations taking steps to identify and diminish preventable
errors and reduce costs associated with such incidents. On the other
hand, it is unlikely that wrong-site-surgery will be fully reported
due to voluntary reporting in various states, the impact on industry
image, fear of litigation, and the difference of opinions between medical experts.
Santosuosso: I believe and hope it is on the decline. It is not something that can be completely eliminated but improvements are being
made every day to policies and procedures. I think patients are being
more proactive and involved with their care, and they are checking
that these safety measures are taken to avoid adverse events. They
sometimes come in and have marked their own limbs prior to surgery, writing with a pen or marker in fear of the worst.
SP: What types of products are most effective at
preventing wrong-site surgery?
Mary Hannon, Marketing Manager, Aspen Surgical: Surgical skin
markers are one of the most prominent products used to support
correct-site surgery. Such products are used to mark the surgi-
cal site prior to skin prep. They can be used as part of the Joint
Commission’s Universal Protocol to help ensure staff is performing
the correct procedure on the correct patient. Because this is done
prior to the patient even entering the operating room, it could be
considered one of the first steps in providing clear communication in
order to avoid wrong-site surgery. Within the skin marker category,
a variety of ink, tip, and body styles are now available to meet the
varying needs and preferences of hospital staff. In addition to surgi-
cal skin markers, there are also a series of products designed to help
assist in the Time Out process required by the Joint Commission.
Products that support this process include highly visible towels,
beacons, and instrument covers that can be placed over the surgi-
cal instrument site, tray, or instrument. In this way, they serve as a
reminder of the importance of performing a Time Out.
SP: Are the standards, protocols, and processes
out there enough to effectively prevent these
problems from occurring? Why or why not?
Taylor: Healthcare professionals have an obligation to comply with the
Joint Commission’s Universal Protocol. Current standards, protocols,
and processes will be more effective when barriers to implementation are
addressed and eliminated. If all healthcare facilities adopt and enforce the
Universal Protocol and surgical teams are consistently in compliance, a
significant reduction in wrong-site surgery is possible.