Industry experts weigh in on the best, and often most simple ways to avoid the tragic
results of a wrong-site surgery.
According to Lisa Spruce, DNP, RN and Director of Evidence-Based
Perioperative Practices for the
Association of periOperative
Registered Nurses’, “One of the very
first things any surgical team must
do is acknowledge that a wrong site
surgery can and does happen and it
can happen to anyone. “
She feels that taking this first
step is essential in keeping safety
at the forefront of every operating
and procedure room. “Surgical
teams need to have good com-
munication skills and not be afraid to speak up if there is
any concern or questions about the procedure being per-
formed,” she continues.
Pam Werner, MBA, BSN, RN, CNOR and Latisha
Richardson, MSN, BSN, RN, who are also part of Ansell's
clinical team, offer a similar sentiment. They feel that since
an Institute of Medicine Report issued
over 15 years ago, surgery departments
all over the world have learned more
about preventable never events. “The
operating room is itself a very complex
system with many moving parts. It can
be hazardous to both clinicians and
patients alike,” they state.
All three also agree on the impact of instituting simple,
yet specific actions targeted at avoiding wrong site surgeries.
Spruce offers the following:
1. Actively involve the patient, make sure they know and
understand their own surgery and what the surgical
site is. Oftentimes the patient doesn’t know and that
can be the first place a mistake is made.
2. Ask the patient several questions and require them
to describe the surgery they are having and where on
their body they are having surgery.
3. Build in safeguards to identify possible errors. The
Joint Commission Center for Transforming Healthcare
Resources has tools that show safeguards that can be
implemented at every level.
4. Make sure to have a relationship with the physician’s
offices that are scheduling the surgery. This is the first
time the patient information is relayed to the surgical facility and if this information is incorrect then an
error can occur.
5. Confirm the accuracy of the surgical schedule and obtain
the following information:
• The correct spelling of the
patient’s full name; patient’s date
of birth; procedure to be per-
formed; the physician’s name; and
implants required, if applicable.
• Require computer automation
for surgery scheduling.
• Educate the surgery scheduling
• Write out (do not abbreviate) the
words “right,” “left,” or “
bilateral” on the OR schedule and all
relevant documentation (
including consent forms) for scheduled
procedures that involve anatomical sites that have laterality.
6. Confirm the presence and accuracy of primary documents critical to the verification process. (signed surgical consent, history and physical, physician orders)
7. Complete a perioperative checklist that includes a pre-procedure verification, site marking and a time out.
8. There are many elements of a time out that must be
implemented but every team member should have the
Director of Evidence-
Practices for AORN
(Above) Proper surgical
marking is one simple
step to avoid wrong site
surgeries. As is proper