Two Wrongs Making a Right:

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Two Wrongs Making a Right:
AORN Pushes 'Patient Safety First' Campaign

By Kelly M. Pyrek

Medical errors and wrong-site surgeries had been making headlines long before the Institute of Medicine (IOM) issued a report in 2000 that focused on the substantial number of these errors, the financial cost and the resulting toll in patient pain, suffering and death, but this report triggered numerous initiatives within the medical community and in the government. Among those leading the charge is the Association of periOperative Registered Nurses (AORN) with its Patient Safety First initiative, a comprehensive patient-safety campaign for implementation in operating rooms and surgical centers nationwide.

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) defines wrong-site surgery as any surgery performed on the wrong site or patient or performing the wrong procedure. To address this problem, it unveiled its sentinel event policy in 1996, providing a mechanism for healthcare facilities to report sentinel events such as patient injury, medication or equipment errors and wrong-site surgeries. While the IOM report stated that medical errors are accountable for as many as 44,000 to 98,000 deaths annually, the actual incidence of wrong-site surgeries is largely unknown - although several groups have produced varying data. JCAHO says approximately 197 wrong-site surgeries have been reported through the agency's sentinel event tracking system since 1995. The Physicians Insurers Association of America reports 225 claims for orthopedic wrong-site surgery and 106 claims for other surgical specialties -- data culled from 22 medical malpractice carriers representing 110,000 surgeons.

A Harvard University study reported that adverse events occur in 7 percent of all hospital admissions; of those, short-lived disability resulted in 70 percent of the cases, while in 7 percent of cases, adverse events led to patient death. The study said medical errors account for as many as 180,000 deaths annually, more than are attributable to motor vehicle or workplace accidents.

Donna Watson, RN, CNOR, president of AORN, believes numbers like those from the IOM report are "significantly understated."

"We traditionally have practiced in cultures that have a tendency to place blame on individuals when an error occurs vs. blaming a system," Watson adds. "So you may have a lot of near misses but the healthcare facility doesn't report them because it fears punitive actions will follow." Watson says she knows of one facility that reported more than 75 near misses in one month, and suspects this might be a common occurrence. She says AORN's Patient Safety First initiative includes the establishment of an anonymous error-reporting system to provide a safe forum in which healthcare providers in the perioperative arena can report their transgressions and seek ways of helping prevent future accidents. AORN has established a hotline and Web site so healthcare professionals can ask safety-related questions, share comments and suggestions, and report concerns and/or incidences of surgical error. The Patient Safety First hotline number is (866) 285-5209; the Patient Safety First Web site is located at

Patient Safety First is sponsored by Sandel Medical Industries.

"We want nurses and doctors to be able to report errors and near misses anonymously so we can learn from their mistakes and take action to correct them," Watson said. "We're looking for stories and information about what actually happens in the operating room."

There are numerous human factors in the perioperative setting that increase the risk for wrong-site surgery, Watson says, and they include:

  • Incomplete or inadequate communication among surgical team members
  • Inadequate patient assessment or identification
  • Pressure to reduce operating room turnover time
  • Reliance solely upon the surgeon to determine the correct surgical site
  • A lack of uniform policies and procedures and control mechanisms
  • Special patient characteristics such as morbid obesity, etc.
  • Unusual equipment or unfamiliar set-up in the operating room
  • Illegible handwriting or use of abbreviations
  • Having more than one surgeon involved in a procedure or performing multiple procedures on multiple body parts during a single surgical encounter

In the end, it may come down to communication and team interaction, Watson says.

"From my experiences, on any given day, you have different teams coming in and out and it's amazing to see how well certain teams work together and others that don't."

Teamwork is also needed between patients and surgical team members, Watson emphasizes, alluding to the fact today's healthcare consumers are more informed than ever before.

"We live in a society in which people are much more participatory in their healthcare than in the past, so it's not unusual to have a patient show up with a plethora of information when they come in for an office visit. My job is to sort out the information that is backed up by scientific research vs. poor information from unreliable sources. Having the correct information helps them make informed decisions and encourages them to become more involved in their surgeries."

However, Watson cautions, "Having the patient more involved does not relieve any healthcare professional from their duty of care. But in the past, it was 'doctor knows best.' Today, while healthcare providers have the training and expertise, sometimes it's not always them who know best; it's the patient who is living the surgical decisions and it's the patient who must also participate in his or her care."

AORN's "Advice for Patients Concerned About Correct Site Surgery" document is a set of guidelines for patients to use prior to undergoing a surgical procedure in order to ensure a positive outcome. The guidelines are:

1. Be an active member of your healthcare team by taking part in every decision about your health care.

2. If you are having surgery or another invasive procedure, make sure that you and the healthcare professionals treating you all agree on exactly what will be done during the surgery or procedure.

3. Verify the information on your patient identity bracelet. Alert a member of the healthcare team if the information is incorrect and insist that it be replaced immediately.

4. Make sure the operative permit you sign includes the correct information about your surgical site (i.e., right or left) and procedure. Thoroughly read all medical forms and make sure you understand them before you sign any forms.

5. Ask to have the surgical or procedure site marked on your body with an indelible marker. If possible, be involved in marking the site.

6. Ask questions and speak up if you have any concerns. Keep asking questions until you understand the answers. Ask members of the healthcare team what steps will be taken to ensure your safety and correct site surgery.

7. Take a responsible family member or friend to accompany you to your doctor's visits and on the day of your surgery or procedure so that they can serve as your advocate and speak up for you if you are unable.

8. Ask that your surgical team include a registered nurse who is a member of AORN.

On the flip side, surgical team members can take the following actions recommended by AORN to ensure correct-site surgeries:

  • Engage in ongoing and effective communication
  • Encourage the patient to actively participate in the perioperative process
  • Maintain the highest levels of patient care
  • Practice interdisciplinary collaboration
  • Engage in accurate and legible documentation

AORN also suggests the following guidelines for creating a surgical-site verification policy for your facility:

  • All patients undergoing surgery will have the surgical site, level and laterality confirmed by the entire surgical team before any procedure is performed
  • A checklist will be used for every surgical encounter to document verification of the surgical site
  • The verification checklist must be completed in its entirety; each person completing any portion of the checklist must initial that portion of the list and the surgery must be postponed if the checklist is incomplete
  • Any surgical site discrepancy noted during the verification process will result in an immediate halt of the surgery until the discrepancy can be resolved

Post-operative complications join the list of risks being monitored by JCAHO. In its review of 64 cases related to operative and post-operative complications, it found that 84 percent of these complications resulted in patient deaths while 16 percent resulted in serious injury. Fifty-eight percent of the complications occurred during the post-operative period; 23 percent were intraoperative; 13 percent occurred during post-anesthesia recovery; and 6 percent were during anesthesia induction. The most frequent complications were:

  • Nasogastric or feeding tube insertion into the trachea or a bronchus, usually involving failure to confirm placement
  • Massive fluid overload from absorption of irrigation
  • Open orthopedic procedures associated with acute respiratory failure and cardiac arrest in the operating room
  • Endoscopic procedures with perforation of adjacent organs
  • Central venous catheter insertion into an artery
  • Burns from electrocautery used with a flammable preparation solution

Facilities can help their healthcare personnel avoid complications by implementing the following risk-reduction action steps:

  • Offering staff training and ongoing education
  • Standardizing procedures across settings of care
  • Defining channels of communication
  • Revising the competency evaluation process
  • Monitoring consistency of compliance with procedures

AORN will expand the Patient Safety First program to focus on additional priorities such as medication safety, infection control, counts and more. The list of safety areas to be addressed also includes patient positioning, communication, blood transfusion, retained foreign objects, burns, fires, equipment failure and staffing.

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