This article appeared in the March 2016 issue of Surgical Products. To see more, click HERE.

Of the never events, wrong site surgery (WSS), often combined into wrong site, wrong procedure, wrong patient errors (WSPEs), offer great potential harm for both clinicians and patients. The patients are left physically and emotionally scarred from the procedural mistake, and clinicians could face:

• Malpractice suites
• Penalties from state licensing boards
• Unpaid reimbursement from some insurers and the Centers for Medicare and Medicaid Services
• Internal consequences from the facility

These mistakes are considered to be fairly rare, but no real numbers can be supplied, since the only national reporting system is hosted by the Joint Commission, which makes it voluntary. The commonly used statistic for WSS is one in 112,000 procedures results in a WSS, but this number does not include ambulatory surgery centers or veteran affairs centers, which experts estimate are more apt to WSPEs. Yet, since the Joint Commission has established the program, the number of reported procedures has increased annually; this is not tied to an increase in WSS, but to an increase is reporting. In total, the Joint Commission estimates about 40 WSSs happen weekly across the nation, but, again, this number’s foundation is not concrete.

Randomized clinical studies are also lacking. So, while protocol developed by the Joint Commission, and professional organization, including the Association of perioperative Registered Nurses (AORN) and the American Association of Orthopaedic Surgeons (AAOS), is assumed to help, numbers do not clearly support it.

Information not missing from the picture is how and why these mistakes happen. Numerous reactionary case studies have been conducted, and the Joint Commission released its latest cause-and-solution breakdown in 2104. The conclusion is simple – these situations are the product of no single root cause, and multiple factors contribute both in the days before and the day of surgery. Commonly, the mistakes stem from communication failures, procedure noncompliance and leadership issues. Before the day of surgery, common mistakes include:

• Inconsistently or incorrect communication from non-affiliated centers, including unapproved abbreviations and codes
• Incomplete documentation, including forgotten or incomplete forms
• Incomplete booking, often between unaffiliated facilities, including inconsistent systems and appointment information requirements

Common mistakes the day of the procedure before surgery include:

• Incomplete or missing documentation that remains unnoticed
• Lack of patient verification, including of name, procedure and patient history
• Failure to communicate changes to procedure

Common mistakes in the OR include:

• Failure to clearly mark the surgical site, which commonly include the mark being washed off or forgetting to mark the surgical site
• Failure to verbalize key ‘Time Out’ components, such as patient name, surgical site and procedure
• Rushing a ‘Time Out’

The Joint Commission also noticed case-specific issues increased the likelihood for WSSs. They included:

• Emergency cases
• Multiple surgeons
• Multiple procedures
• Obesity
• Deformities
• Time pressures
• Unusual equipment
• Unusual room setup
• Changes to the room

Even if the reasoning behind WSS is explained and the correct percentage is established, what remains is the changed reality for the surgical team, the patient and the patient’s family when these mistakes occur. To see how clinicians approached wrong site surgery prevention, Surgical Products connected with its readers. The universal conclusion was technology can lend a hand, but the human component necessary to surgery would always present risk of error.

The ‘humanness’, as one reader described it, would rush the Time Outs because of the ‘it won’t happen to me mindset’. Although most readers said they always felt confident they could speak up if they noticed an inconsistency, 10 percent of people admitted that sometimes the workplace culture held them back. “A lot of attention has been placed on speed and turning rooms over quickly. Give the staff time to use the tools they have and spend more time with patients preoperatively,” suggested one anonymous reader.

When asked ways to prevent WWS and other never events, clinicians suggested what the Joint Commission, AORN, AAOS and other associations already have – patient participation and verification in the safety checklist, clearly and consistently marking surgical sites and streamlined communication. They also got more creative – suggesting checklist apps, electronic medical record software that removed the human element to paperwork and random procedure audits.

Surgical Products surveyed its digital subscribers electronically in January, and more than 100 readers, mostly identifying as clinicians, responded.