Wrong-Site Surgery Update
There were eight event reports of wrong-site surgery in Pennsylvania operating rooms (ORs) during the third quarter of 2014 and two reports belatedly confirmed from a prior quarter (see the Figure). The eight reports matched those of the second-lowest quarter ever and were the lowest number of reports for the beginning of an academic year (July through September).
Six of the reports involved injections: one unwanted preoperative regional block, one preoperative regional block done on the wrong side and attributed to the lack of an “all stop” time-out, two wrong-side pain injections, and two preliminary local blocks by the surgeons prior to any time-outs, as noted below:
Surgeon preinjected the right ear instead of the left ear per consent. He realized his mistake as he was preparing to drape the patient.
Prior to [the surgeon] coming into the room, the patient’s left foot was put up on a prep pillow and wrapped with Webril™. This was the nonoperative side. When the surgeon came into room, he proceeded to inject that foot. He injected 1 mL. [Then, he] stopped and questioned which side we were working on, and the nurse said the right. . . . The right foot was then prepared for injection, and the procedure was completed as scheduled.
Two reports were of surgery on the wrong finger. One was related to accepting nonspecific information on the consent and from the patient:
Patient’s surgical consent read “trigger finger release right.” When the circulator asked the patient what he was having done, the patient replied, “I’m having one of my right trigger fingers released. I need them all done.” While the patient was making the previous statement, he was pointing to the mark identified by both the patient and the surgeon in the holding area, which was located below his right third finger. Documentation reflected patient’s initial complaint in the surgeon’s office was of his right trigger thumb.
Numerous near-miss reports continue to demonstrate persistent areas of risk and the effectiveness of practices that prevent wrong-site surgery.1,2
This past quarter, more than a dozen procedures were scheduled incorrectly, with potential downstream ramifications:
Patient in holding area; wrong side on consent for surgery and OR schedule. Left side was indicated on consent as well as on the OR schedule, when it is the right side that needs the surgery. Discussed with family (patient is demented), who did not know which side. It was found by reading the HP [history and physical], which indicated it was the right foot that was injured. . . . The old consent was discarded and a new consent obtained.
The [scheduling] error was not discovered until the patient entered the OR, where the RN picked up on the discrepancy. . . . Although the pre-op holding RN did check the schedule, he did not notice the scheduling discrepancy.
More than 30% of the incorrectly scheduled cases documented the surgeon’s office as the source of error:
The case information was forwarded to the chair[person], who discussed it with [the surgeon] because this was the third case this year from that office that a procedure site was scheduled incorrectly.
The office scheduling sheet was pulled and clearly states left. . . . The patient was marked for the correct side that corresponded with the consent, the right [side].
Monitoring the accuracy of information from surgeons’ offices is important because 11% of all wrong-site operations can be traced back to incorrect information from surgeons’ offices.3,4
Fortunately, providers receiving patient information check for discrepancies and identify them as soon as discovered for reconciliation by the surgeon, based on primary sources of information:
Schedule did not have full procedure listed. Called to PAT [preadmission testing] department to have schedule corrected prior to the day of surgery.
At least 10 consents were incomplete or inaccurate, some to an extent suggesting that the informed consents were not obtained by the surgeons:
Surgical consent did not list any procedure to be performed. Patient already given sedating medicines.
When verifying the procedure with the patient, the patient reported that he was having an appendectomy. The consent indicated “laparoscopic, possible open, cholecystectomy.”
Preregistration came from office clearly stating “carpal tunnel release.” Registration entered “Colonoscopy.” . . . Consent stated the incorrect procedure.
Surgeons are not always doing a proper preoperative verification of the documents, with confirmation by the patient:
[Surgeon] entered the room while the patient was being fitted for a TLSO [thoracolumbar sacral orthosis] brace. The [surgeon] did not identify the patient and proceeded to dilate the incorrect patient’s eye [preoperatively].
Patient arrived in the OR visibly concerned. Patient stated that a doctor came into her room in the holding area . . . and marked her left hip for hip surgery. The patient is not here today for hip surgery and was concerned arriving to the OR if she was going to receive the correct care. I went over her consent with her in great detail, and she agreed that she was here to have neck surgery.
The correct identities of at least four patients were ascertained only by checking the patients’ identifiers in the preoperative holding areas or ORs:
CRNA made decision to take fourth patient on schedule back to OR instead of [third patient on schedule] . . . because the third patient’s family had just taken her CPAP [continuous positive airway pressure] equipment back to their car. CRNA did not notify the surgeon, the OR team, or the preoperative nurse that she was taking a patient out of order.
A physician called the OR to schedule an emergency C-section on a patient but did not mention the patient’s name or room number. The nursing supervisor was notified, and she provided the wrong patient’s name and room number. The OR was scheduled under the wrong patient’s name. During the surgical time-out, staff discovered the wrong patient had been scheduled due to misinformation by the nursing supervisor. The correct patient was in the OR.
In at least three reports, the information on the white board in the OR was incorrect prior to the time-out:
Patient and paperwork confirms cataract surgery on the left eye. Dry-erase board lists cataract surgery on the right eye. Dry-erase board changed to reflect the correct eye. This was changed before the “time-out.”
Surgeons do not always participate in a time-out:
Physician began surgery without doing a time-out. This was realized approximately six minutes into the procedure, and the time-out was completed.
Two reports illustrate the difference between a properly done time-out and a poorly done time-out:
Patient was having right knee surgery. The tourniquet was applied on the left leg. The patient was prepped and draped for left knee surgery. During time-out, it was confirmed that the right knee was the operative knee. The drapes were removed and the correct leg was prepped and draped.
CRNA was relieved for a break minutes before the time-out. One of the elements of the time-out is [verifying that] the antibiotics are given. Two grams of Ancef ® were ordered, and . . . none had been documented. . . . I . . . gave the patient the 2 grams at 0936. . . . When [the CRNA] returned from her break, I asked her to reverify the time the Ancef was given, and she reported that she had given the patient 2 grams at 0904.
Electronic Records: Are They Always Helpful?
In theory, electronic records can help implement evidence-based best practices to prevent wrong-site
surgery.1,2 Electronic scheduling can ensure that the specific site is included when an operation is scheduled. Electronic records are more accessible by everyone who is in a position to identify discrepancies among the documents in the preoperative period. Primary source documents are more readily accessible when reconciliation of discrepant documents is necessary. In the OR, all documents can be displayed on monitors that are visible to the entire OR team. Intraoperative verification by radiographic confirmation can be done more rapidly by both the surgeon and radiologist.
In response to the following edited query from a facility, the Pennsylvania Patient Safety Authority looked for events implicating electronic records:
I’m looking for any best practices that are available that discuss the inclusion of validating that the correct EMR [electronic medical record] is open/selected as part of the surgical time-out process. Currently our time-out policy does not address the validation of the correct anesthesia and OR EMR as part of the surgical time-out. Has the Pennsylvania Patient Safety Authority received any events related to the incorrect anesthesia or OR EMR being used for documentation of the care of the surgical patient although the patient and procedure were correct and verified through consents and patient identifiers?
A review of the near-miss reports from this past quarter identified the following:
Patient stated operative site is left leg. MD consent identified left leg. NaviCare system and Epic system indicate right leg. Site confirmed and performed on correct leg.
During the time-out, the image of the consent would not load on the computer. Attempts to print the consent were not successful. Staff had visually seen the consent prior to the time-out, and the procedure was completed due to the high risk of awakening the patient and a delay of the surgery.
Patient was prepped and draped for a left partial nephrectomy. Surgeon halted the surgery due to inconsistency with radiology films that were displayed in the operating room. The charge nurse and administrators were then notified of the situation. Surgeon reevaluated the radiology films and report and determined that incorrect films were placed in patient’s [electronic medical] records. Surgeon . . . determined that the left kidney was [nevertheless] the correct kidney.
All surgical paperwork on the chart stated right carpal tunnel release, which was correct. H&P [history and physical] stated left carpal tunnel release. Pre-op nurse noted the discrepancy prior to the admission of the patient to pre-op. Correct H&P was located in the patient’s electronic medical record. Patient had a left carpal tunnel release performed prior to this date of surgery, and preadmitting testing pulled the wrong H&P from the [patient’s electronic] medical record.
The Authority hypothesized that electronic systems were capable of having incorrect information entered, just like paper records. It also hypothesized that electronic systems could make it easier to access archaic or outdated information, when more recent information is
Analysts reviewed the complete registry of 596 wrong-site operations. There were 12 wrong-site procedures based on another patient’s information, a contributing factor that is not unique to an electronic record:
- A pathology report of cancer, attributed to the wrong patient during dictation, was the basis for surgery.
- Wrong radiographs were used to localize the lesion.
- Another patient’s H&P was mislabeled, incorrectly included in the chart, and used as the basis for
- Another patient’s consent was mislabeled in the surgeon’s office and incorrectly included in the chart.
- The surgeon called his office and got incorrect information from the office charts. (Presumably, this communication error might not have occurred with compatible electronic office records.)
- The patient was accompanied by another patient’s chart.
- The patient, identified by passive query, was the wrong patient.
- The patient was operated on out of order without any identifiers
- In the OR, the surgeon consulted the wrong patient’s office chart.
- Three patients were confused with other patients with the same name and similar problems.
One patient received a different procedure than intended as a result of staff accessing the wrong information electronically. He had consented to a procedure. The consent was in the electronic system. He then changed his mind and requested a different procedure. The consent for that procedure was in the electronic system; however, there was no mechanism for labeling the original consent as void and superseded by the second consent. The original consent was accessed electronically and used as the reference for the intended procedure.
The Authority concludes that wrong-site errors due to incorrect information in the patient’s record or the incorrect patient’s record are possible with both paper and electronic records. Outdated information may be easier to access electronically. Consider making sure that the name of the patient and the date of the document are easily identified in electronic records. Additionally, consider an electronic method for time-stamped notations for corrections of information.
- Pennsylvania Patient Safety Authority. Principles for reliable performance of correct-site surgery [online]. 2012 [cited 2014 Jul 17].
- Quarterly update: the evidence base for best practices for preventing wrong-site surgery. Pa Patient Saf Advis [online] 2010 Dec [cited 2014 Jul 17]. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/dec7(4)/
- Clarke JR. Is your office helping you prevent wrong site surgery?
Bull Am Coll Surg 2014 Apr;99(4):28-31. Also available at
- Pennsylvania Patient Safety Authority. Monitoring of preoperative information from surgeon’s office available at first encounter [online]. 2012 [cited 2014 Nov 6].