Pa Patient Saf Advis 2016 Sep;13(3):124.
Saves, System Improvements, and Safety II
Internal Medicine and Subspecialties; Nursing; Pediatrics; Surgery
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"Saves, System Improvements, and Safety II" is an occasional feature of the Pennsylvania Patient Safety Advisory, highlighting successes by healthcare workers in keeping patients safe. The Safety II approach assumes that everyday performance variability provides adaptations needed to respond to varying conditions and that humans are a resource for system flexibility and resilience.

Site Marking: Undoing an Error

A patient was scheduled for a right hip replacement but the surgeon marked the left (incorrect) side.* Recognizing the error, the surgeon immediately drew an “X” through the incorrect mark, added the word “wrong,” and marked the right (correct) hip. The nurse recognized the potential for confusion and used alcohol to remove the incorrect mark, including the word “wrong.”

This event narrative exemplifies correcting an error before harm could occur. Although members of the surgical team can do their best to prevent errors, errors may still occur. In this instance, the surgeon immediately corrected the error, before harm occurred, and the nurse reinforced the correction. There is limited information in the event report, but it’s intriguing to consider the participants’ possible thought processes. When the surgeon not only crossed out the incorrect mark, but wrote the word “wrong,” it’s possible that he or she anticipated that crossing out the mark alone might still be incorrectly interpreted as “X marks the spot” so the word “wrong” may have been added to provide additional clarification. When the nurse saw two site marks, he or she may have considered the possibility that additional team members might proceed based on the first mark they saw, which could be either the correct or incorrect mark, and not look for an additional site mark. Advisory information that may help prevent wrong-site procedures is available here. Part of keeping patients safe involves following evidence-based processes, and part involves being able to effectively manage uncommon or unanticipated conditions.

This is a good catch because the surgeon and nurse corrected the site-marking error before harm occurred (i.e., preventing a wrong-site event). Often protocols describe the expected course of action; it’s much less common for protocols to provide guidance on how to correct errors. Kudos to the team’s members for their situational awareness in an uncommon situation.

* The details of the PA-PSRS event narrative in this article have been modified to preserve confidentiality.


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