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Archive January 2021 XXII, No. 1

Positioned to Prevent Wrong-site Surgery

Reinforcing a culture of safety will ensure surgeries are performed as planned.

Maria Marabito

Maria Marabito, Contributing Editor


SPOT ON Surgeons meet with patients to confirm the scheduled procedure and sign their initials at the correct surgical site.

Adverse events involving wrong-site, wrong-side and wrong-patient errors are devastating outcomes for surgeons who must live with the mistakes and patients who suffer unnecessary physical scars. These never events persist because of inconsistencies in implementing proven steps to prevent them. Ensuring surgeons perform the correct procedure on the right patient at the intended site requires a multidisciplinary effort and refocusing on the importance of building a culture of safety.

University of Pittsburgh Medical Center (UPMC) facilities are known for adherence to strict patient safety measures, including a series of steps designed to prevent wrong-site surgery. The effort begins long before patients are wheeled into the OR.

  • Confirm with schedulers. Surgeons' offices send in surgery reservation sheets, which note patients' names and details about the procedures they're scheduled to undergo. A day before scheduled cases, UPMC staff members call surgeons' offices to review the list of patients and confirm the correct procedures, and then add the information to the surgical schedule in the health system's electronic medical record.
  • Perform multiple checks. The reservation sheet is forwarded to the pre-op testing department, where staff verify the correct procedure when they call patients to collect standard health histories. In pre-op on the day of surgery, staff members ask patients to confirm their names, dates of birth, procedures and surgical sites, and make sure each identifier matches what's noted on charts and consent forms. Surgeons arrive to confirm the scheduled surgeries with patients and sign their initials at the correct surgical sites. When patients enter the OR, the circulating nurse asks them to introduce themselves to the surgical team and confirm the procedure they're about to have. Then, during the time out, every member of the surgical team once again confirms the correct surgical site.

During daily morning huddles, the surgical team mentions if patients with the same or similar last names will be undergoing surgery that day so they're more focused than usual in ensuring the correct procedure is performed on the intended patient.

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