AORN and the Joint Commission addressed the healthcare community in a letter on National Time Out Day, which was Wednesday, June 10. They wrote:
Dear colleagues, associates, and friends,
Surgery on the wrong patient or wrong body part is called a “never event” because it’s never supposed to happen. But it does with depressing regularity, and it’s not acceptable. Exact numbers are difficult to find because reporting is most often voluntary, but wrong site surgeries occur an estimated 40 times a week, or five times a day, in the United States, based on figures from states with mandatory reporting requirements.
The human damage of a wrong site surgery is immeasurable. Patients are physically and emotionally scarred, and sometimes a life is lost. The entire surgical team is devastated too.
On June 10, we mark the 11th anniversary of National Time Out Day, an event that draws attention to the need for everyone on the surgical team to pause before the procedure begins in order to make sure they are operating on the right patient, the right site and they are performing the right procedure. As we mark this milestone, we bring new research to bear on the issue of wrong site, wrong side, wrong procedure events. For years, we have focused on the providers, the men and women at the surgical table. We now have evidence that we must examine the entire surgical process, starting when the procedure is scheduled. And we must engage the entire health care team, including the patient and his or her family, in the pursuit of surgical patient safety.
In 2004, The Joint Commission, the nation’s top accreditation agency for hospitals and ambulatory surgical centers—and a catalyst for high reliability in health care—introduced a simple process for preventing wrong site surgery.
The Universal Protocol, as it is named, calls for the surgeon to confirm the procedure with the patient and to mark the body part to be operated on; and for every member of the surgical team to participate in a time out before operating to ensure that the correct procedure is about to begin on the correct part of the correct patient.
AORN responded to the Universal Protocol by creating the National Time Out Day to raise awareness. In 2010, AORN also developed a combined surgical safety checklist to give individual facilities the option to meet The Joint Commission’s Universal Protocol and the World Health Organization’s standards while customizing the checklist according to surgical specialties.
But in the 11 years since the introduction of National Time Out Day, we have learned that wrong site surgery can stem from a cascade of small errors that penetrate organizational defenses. Surgical errors can originate from a simple typing mistake when the physician’s office schedules a surgery or because of miscommunication in the multiple handoffs among providers caring for the patient.
We should no longer expect humans to be infallible. Rather, we must build in systematic defenses throughout the patient experience to defend against wrong site surgery.
Patients also play a role. In a recent study, when patients were informed about safe surgical checklists, the operating room team did a more thorough job of completing the mandatory pre-procedure verification process.
While our respective organizations continue to gather and analyze the evidence for which approach works best to wipe out this “never event,” patients, administrators and the surgical team can do three very important things:
Surgeons and nurses: Continue to follow the Universal Protocol. It remains our best safeguard yet. Guard against the cultural pressures to make it less than meaningful by fostering a culture in which everyone on the operating room team is encouraged to speak up for patient safety.
Hospital administrators: Understand that errors can take place anywhere in the “layers” of information collected and handed off during the weeks, days and hours before surgery. Rigorously examine your processes to ensure no errors can leak through.
Patients: Be informed and act as your own best advocate. Ask to see your medical care plan and double-check it for errors. Learn about the safe surgery checklist and when you are verbally consenting to or describing the surgery, take it seriously. Make sure the correct site is marked by someone who will be in the operating room during your surgery.
We can realistically imagine a day when wrong site surgeries never happen. To get there, patients and their advocates, surgical teams and their administrators, need to work together to reduce the risk of this catastrophic event.
Mark Chassin, M.D., FACP, M.P.P., M.P.H.
President/CEO of The Joint Commission
Linda Groah, MSN RN CNOR NEA-BC FAAN
Executive Director/CEO of AORN
