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Patti Sligar, RN (left), nurse manager, verifies patient ID, the procedure, and the surgical site at the main OR at Metropolitan Methodist Hospital in San Antonio.

Dr. Jones drilled through the skull to expose the patient’s brain. He was prepared to remove the large tumor he’d seen on the patient’s X-ray just a few minutes before surgery. But the tumor wasn’t there.

“Get me the X-ray,” Jones said. It was his worst nightmare. Someone had reversed the film on the X-ray view box. He had begun surgery on the wrong side of the patient’s brain.

TIME OUT Safety Kit photo courtesy of
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Most nurses have heard about mistakes like this one, or even whispered about surgical errors they’ve witnessed in their own units — the wrong leg removed, surgery on the wrong side of the body, or the wrong procedure performed. Although the Joint Commission on Accreditation of Healthcare Organizations reports only 250 cases since 1995, the effects are tragic. As Association of periOperative Registered Nurses President Bill Duffy says, “One is too many.”

In response to continued reporting of surgical errors, JCAHO established the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. As of July, 4,700 JCAHO facilities were required to implement the protocol.

“The need to reduce medical errors began to enter the medical community’s radar screen with the 1999 Institute of Medicine’s report,” says Patricia Seifert, RN, MSN, CRNFA, FAAN, chair of the AORN Presidential Commission on Patient Safety. The IOM’s report To Err is Human: Building a Safer Health System broke the silence that surrounded medical errors, estimating 98,000 deaths annually.

“JCAHO’s universal protocol raises the bar for health care with patient safety goals,” says Don Guajardo, RN, BSN, director of perioperative nursing at Northridge (Calif.) Hospital Medical Center. “We’ve always embraced the goal of eliminating wrong-site surgery, but now the process to ensure patient safety has been addressed on a national level.”

As safe as 1, 2, 3

The causes of surgical errors are numerous. They include OR schedule changes, time pressures, and missing patient information, nurses say. Distraction can cause a health care professional to insert an IV into the wrong arm and the surgeon to accidentally operate on the “good” one. The multiple hands through which patients pass from admissions to preop also provide ample opportunity for communication errors.

“Lack of communication is a major factor that can cause OR staff, surgeons, and anesthesia to make incorrect assumptions that lead to surgical errors,” Guajardo says.

JCAHO’s protocol tackles the communication problem in three steps: improving the preoperative verification process, marking the operative site, and introducing a “time-out” for the surgical team to make sure all members agree about the identity of the patient, the procedure, and the surgical site.