Page 60 - 2022 Risk Basics - Surgical Practice

SVMIC Risk Basics: Surgical Practice

 a final timeout just prior to the operation or procedure,

regardless of where it is being performed.
13

All healthcare providers performing invasive procedures must
adopt the Joint Commission Universal Protocol, including

performance of a timeout immediately prior to the procedure.
Wrong-site surgery is a sentinel event, as defined by The Joint

Commission’s Sentinel Event policy, which requires

organizations to conduct an immediate, comprehensive
systematic analysis and respond to the event.

SVMIC Analysis

In our analysis of the reasons for a surgeon to perform surgery

on the wrong site or perform an incorrect procedure, we
identified systems issues which contributed to these events.

One factor that contributed to wrong-site surgery was related
to illegible or conflicting medical record entries with respect to

the correct operative site. This does not only occur with the

physician’s notes, but might also be found on surgery
scheduling forms that contain abbreviations or missing

information which can confuse the scheduler or other OR
personnel involved in the surgery. Adopting the use of

standard abbreviations, or writing out the words that describe

the side or site, can greatly reduce the risk of misinterpretation
of the correct site for the procedure.

Inconsistent site-marking can lead to wrong-site surgery.

Understanding exactly how the operative site is marked and
verifying that everyone is aware of the appropriate marking

13 https://psnet.ahrq.gov/webmm/case/177/the-inside-of-a-time-out

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