In April 2023, the Joint Commission published its “Sentinel Event Data 2022 Annual Review.” Leaders of patient care organizations rely on this annual report for an understanding of the U.S. healthcare system-wide sentinel events that are the most significant. And while “wrong surgery” is not one of the most common sentinel events that take place in U.S. hospitals every year, when it happens, the impact is potentially devastating and even life-threatening. In its report, the Joint Commission noted that consistent with previous reporting patterns, most reported sentinel events in 2022 occurred in the hospital settings (88 percent). Leading event types associated with the hospital setting included falls (45 percent), unintended retention of foreign object (7 percent), and wrong surgeries (6 percent). In the behavioral health setting, leading event types were patient suicide (23 percent), falls (18 percent), and delays in treatment (16 percent). Fires (e.g., smoking while on oxygen) (43 percent) and patient falls (20 percent) were leading event types in the home care setting. Wrong surgeries (25 percent), patient falls (22 percent), and fires (16 percent) were leading event types in the ambulatory care setting, and patient falls (43 percent) and perinatal events (14 percent) were leading event types in the critical access hospital setting.
The report defines “wrong surgery” as a “surgery or other invasive procedure performed at the wrong site, on the wrong patient, or that is the wrong (unintended) procedure for a patient regardless of the type of procedure or the magnitude of the outcome.”
Of the 85 wrong surgeries documented by the Joint Commission in 2022 (compared with 119 in 2021 and 94 in 2020), 65 percent involved the wrong site; 17 percent involved the wrong procedure; and 9 percent each involved the wrong implant or the wrong patient.
An important backgrounder published in September 2019 by the federal Agency for Healthcare Research and Quality (AHRQ), through its Patient Safety Network collection of primers, under the title “Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery,” notes that while much publicity has been given to these high-profile cases of WSPEs [wrong-site, wrong-procedure, wrong-patient errors], these errors are in fact relatively rare. A seminal study estimated that such errors occur in approximately 1 of 112,000 surgical procedures, infrequent enough that an individual hospital would only experience one such error every 5–10 years. However, this estimate only included procedures performed in the operating room; if procedures performed in other settings (for example, ambulatory surgery or interventional radiology) are included, the rate of such errors may be significantly higher. One study using Veterans Affairs data found that fully half of WSPEs occurred during procedures outside of the operating room.”
Importantly, the AHRQ primer notes that while “early efforts to prevent WSPEs focused on developing redundant mechanisms for identifying the correct site, procedure, and patient, such as ‘sign your site’ initiatives, that instructed surgeons to mark the operative site in an unambiguous fashion…it soon became clear that even this seemingly simple intervention was problematic. An analysis of the United Kingdom's efforts to prevent WSPEs found that, although dissemination of a site-marking protocol did increase use of preoperative site marking, implementation and adherence to the protocol differed significantly across surgical specialties and hospitals, and many clinicians voiced concerns about unintended consequences of the protocol. In some cases, there was even confusion over whether the marked site indicates the area to be operated on, or the area to be avoided. Site marking remains a core component of The Joint Commission's Universal Protocol to prevent WSPEs.”
In fact, the primer emphasizes, “root cause analyses of WSPEs consistently reveal communication issues as a prominent underlying factor. The concept of the surgical timeout—a planned pause before beginning the procedure in order to review important aspects of the procedure with all involved personnel—was developed to improve communication in the operating room and prevent WSPEs. The Universal Protocol also specifies use of a timeout prior to all procedures,” and the protocol can be applied to all invasive procedures.
Per all this, the Denver-based Association of periOperative Registered Nurses (AORN) provides its members with a wealth of informational resources on best patient-safety practices in surgery on its website. Indeed, AORN offers its members an entire page of links containing information on Wrong Site Surgery.
Per all the latest advice from leading entities like AORN, Mark Hagland, Editor-in-Chief of Healthcare Innovation and a Contributing Editor to Healthcare Purchasing News, recently interviewed Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, senior director of evidence-based perioperative Practice at AORN, about this important topic. Below are excerpts from that interview.
Starting from a 40,000-feet-up view, what is AORN’s overall strategic objective in providing alerts to its members to educate them on wrong-patient and wrong-site surgery?
AORN educates our members regarding the importance of preventing wrong-site surgery through our guideline on Team Communication, which includes establishing a culture of safety and communication tools and the accompanying guideline essential resources. In addition, AORN has an educational toolkit on wrong-site surgery and every year AORN celebrates National Time Out Day on June 14th, when we provide a day where all perioperative teams can review the ways they keep patients safe in every procedure.
Are rates of patient safety errors in this area declining at an adequate pace?
Wrong-site surgery was the third most common sentinel event from 2018-2020; in 2021, it was the second most common; and in 2022, it was the fourth most common. However, these events are voluntarily reported, so actual numbers could be much higher. Of course, even one wrong-site surgery is tragic for patients which is why we aim for zero events.
What do you see as the biggest challenges to achieving near-zero levels of errors in this area?
The perioperative environment is stressful and fast paced, and perioperative team members are under increasing pressure from numerous demands and complex functions that lend themselves to error. The operating room is a high-risk sociotechnical environment with various professionals working in proximity. Effective team communication in the perioperative and procedural environment is the foundation of optimal patient outcomes. Perioperative RNs play a crucial role in facilitating communication among the interdisciplinary team. Research has demonstrated that communication breakdowns in the perioperative setting are a factor in wrong-site surgery. Challenges to adequate team communication and empowerment to speak up are two important issues that need to be addressed.
What is the role of the bedside nurse in reducing and eliminating wrong-patient and wrong-site surgeries?
Reducing and eliminating wrong-site surgeries is really a function of the entire team—not one individual—so it begins with creating a patient safety culture and encouraging individual members of perioperative teams to actively engage in and support the culture. Respecting each other, encouraging honesty, and encouraging nurses to speak up is extremely important for patient safety. Nurses can take the lead on the time out process to conduct a final check that the correct patient, correct site, and correct procedure are identified. This is the time for all perioperative team members to speak up and address any concerns or problems that would affect the safety of the patient.
Can technology help? If so, how?
We recommend the use of a standardized surgical safety checklist during the time out process to improve communication and reduce the potential for errors in perioperative and procedural settings. Using technology to implement the checklist is a great tool to not forget anything critical that is included in the surgical safety checklist. This can be in the form of whiteboards, electronic whiteboards, computerized SSCs, or other emerging technology.
Early efforts to reduce wrong-site surgeries focused on processes such as marking the patient’s body prior to incision. Did such efforts yield positive results?
Yes, focusing on these processes has helped in nationwide efforts to decrease wrong-site surgeries and many facilities across the country that are using standardized processes do not experience wrong-site surgeries. The use of standardization, checklists, and protocols mitigates the human factor risk.
AHRQ has reported that communication breakdowns are actually the most common core cause of wrong-site (and wrong-patient and wrong-procedure) surgeries. What are your thoughts on that finding?
I agree it is one of the most common causes. During our writing of AORN’s guideline for Team Communication we also reported that communication failure and incomplete or missing patient information are the most common contributors to sentinel events such as wrong-site surgery.
How can nursing managers and leaders improve processes?
A culture of safety begins and is led by perioperative leaders. They are of vital importance to set that expectation and to lead the process of standardizing safety processes that are based on evidence. Leaders begin by assessing their culture of safety by surveying their teams on topics such as teamwork, safety climate, job satisfaction, stress recognition, and working conditions that could contribute to an unsafe environment. After they have an idea of the measurement of safety culture in their organization, then they can begin to make improvements such as promoting mutual respect; creating a trusting environment with open communication; establishing a safe platform to report errors, near misses, unsafe conditions, and intimidating behaviors; as well as establishing patient safety goals and implementing communication tools.
Mark Hagland
Mark Hagland is Editor-in-Chief of HPN's sister publication, Healthcare Innovation.
