Archive Staff & Patient Safety 2017

Lessons From 3 Wrong-Site Surgeries

Focus on what really happened, not what's supposed to happen.

Steven Wentworth, RN, CNOR, BSN, MBA


never event NEVER EVENT? It's surprisingly easy for even the most well-intentioned surgical team to operate on the wrong body part.

Of the 3 wrong-site surgeries we had in 6 years at my former hospital, one in particular illustrates how even the slightest deviation from policy can create a crack large enough for a never event to slip through.

It was a right knee replacement.

Or at least it was supposed to be.

The surgeon marked the right (right, as in correct) knee in pre-op, but he wrote his initials low on the leg, not on the surgical site. Once the patient was prepped and draped, you couldn't see the site marking. Two seemingly minor oversights — the surgeon's initials not being over (or as close as possible to) the incision site and not being visible after the patient has been draped — would set into motion a chain of events that would lead to the surgeon cutting into the wrong knee.

Making matters worse, the circulator was distracted, looking ahead to the next case in the next room, instead of focusing her attention on the here and now. Maybe that's why nobody noticed that the team had mistakenly prepped and draped the left leg, not even during the time out, a half-hearted exercise not everybody paid attention to or participated in. Fortunately, soon after the surgeon made his incision on the wrong knee, an astute anesthesiologist spoke up: "Excuse me, but aren't we supposed to be doing the right leg?"

How did he know? Because the surgeon always stands on the opposite side of the leg on which he's operating. This time, however, he was standing on the patient's right side and the anesthesiologist was pretty sure we were operating on the right knee. Even though we caught the error before the surgeon proceeded with the case, technically this went down as a wrong-site surgery because we'd made an incision on the wrong knee. Would the surgeon have replaced the wrong knee had the anesthesiologist not spoken up? Hard to say for certain, but let's just say we're glad we didn't find out.

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