Archive August 2017 XVIII, No. 8

Reducing the Risk of Wrong-Site Surgery

Key defenses in the battle to eliminate preventable harm include the time out, pre-operative verification process and site marking.

Bill Donahue, Senior Editor


wrong-site surgery LONG-TERM PAIN A wrong-site surgery or other sentinel event can result in staggering costs and cause lasting damage to a facility's reputation.

The patient had just been re-draped, re-prepped and re-positioned, from supine to lithotomy, and the surgeon was eager to restart the case — a varicoclectomy followed by a bladder biopsy — without confirming everyone in the OR was on the same page. Lt. Jessica Naranjo, BSN, RN, CNOR, knew better. Instinct took over, and she voiced her concern: "Sir, I'd like to do a second time out for patient safety."

After some initial resistance, the surgeon agreed and the OR team took a second time out to verify the next phase of the procedure. The case proceeded as planned, without incident.

"To be able to stand up to the surgeon and to quote policies and standards I had been taught took a lot of courage," says Ms. Naranjo, a perioperative staff nurse with Naval Hospital Jacksonville (Fla.). "If there's one thing we learn as we're going through our training, it's that you have to stand up for what you think is right."

But not everyone follows her example. Some staff members just don't feel comfortable doing so, because of the OR's traditional surgeon-first hierarchy, or perhaps they fear retribution or maybe they simply haven't been empowered to intervene. It's an especially tough situation for junior nurses, says Cmdr. Julie Conrardy, MSN, RN, CNS-BC, CNS-CP, CNOR, the U.S. Navy's director of the perioperative nurse training program, East Coast.

"But as the patient's advocate in the OR, it's your responsibility to act as the safety net," she says. "Everyone in the OR has to have the confidence to speak up like Jessica did, and that has to start outside of the OR."

Although the above scenario might have ended fine even if Lt. Naranjo hadn't spoken up, the what-if question it raises should send a chill down every facility leader's spine. Her experience — multiple procedures being performed on a patient without a proper second time out — is a textbook example of a situation that could have resulted in an avoidable error capable of causing irreparable patient harm. And it often does.

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