Marks of Safety
Preop safety protocols help teams check blind
spots that will prevent surgical errors

By Lorraine Steefel, RN, MSN, CTN
November 1, 2004

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.

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.

The protocol’s new requirements ensure that patient verification is no longer just a one-time procedure. For example, the verification procedure is first done at the time surgery is scheduled, and again during admission. In the holding area where patients are still awake and aware, nurses and staff once again verify the correct patient, procedure, and surgical site. The procedure also is repeated any time the responsibility for care of the patient is transferred to another caregiver. “We tell patients that we will ask them identifying questions multiple times for their own safety,” says Elizabeth Wein, RN, MPS, CNOR, CNAA, director of perioperative services at Solaris Health System’s JFK Medical Center in Edison, N.Y., and Muhlenberg Regional Medical Center in Plainfield, N.J.

Now, the patient verification process also includes patient involvement. JCAHO states that patients have a role in making their surgical procedure safe by becoming “active, involved, and informed members of their health care team.”

“We ask alert patients to initial their surgical sites to help make surgery safer,” says Sandy Godcharles, RN, preop charge nurse at University of Colorado Hospital in Denver. At some facilities, the operating surgeon initials the site but involves patients when possible.

Although the protocol doesn’t specify the type of mark, JCAHO states that the surgical site marking method [chosen by the facility] must be consistent throughout the organization. Rather than an “X” at the spot, the mark must be unambiguous — the patient’s or surgeon’s initials, the word “YES,” or a line representing the proposed incision. The marker used must be permanent and visible after the patient is prepped and draped. Hospitals must determine a policy for patients who refuse site marking.

“Time-out” is another protocol initiative. Immediately before surgery begins, the surgical team takes a time-out. For a few seconds, the entire operative team comes together for a type of “surgical mindfulness” — awareness in that moment of what they are preparing to do. During the time-out, the surgical team checks that all members agree on the identity of the patient, procedure, surgical site, correct patient position, and the availability of correct implants and any special equipment or requirements. JCAHO suggests that this be documented with the type and amount of documentation determined by the facility.

“The idea to stop and think preoperatively isn’t new,” says Patti Sligar, RN, nurse manager of the main OR at Metropolitan Methodist Hospital in San Antonio. “The time-out formalizes it and takes it to the next level.” During time-out at Metropolitan Methodist, the circulating nurse docu ments the team’s confirmation of verification on a computerized checklist. For additional safety, the perioperative documentation process cannot continue unless every prompt on the site verification screen is answered.

The practical side

The protocol was needed, but some facilities found it difficult to put the new rules in place. “Though facilities had surgical protocols in place, several were struggling. Some had varying interpretations of the universal protocol, and many had questions,” says Pauline Robitaille, RN, MSN, CNOR, chief nursing officer of AORN and vice president for professional services. To help health care providers implement the universal protocol, AORN developed a Correct Site Surgery Tool Kit.

AORN distributed 55,000 tool kits to members, hospital risk managers, and CEOs of hospitals and ambulatory care facilities. The kit provides a variety of resources to educate health care providers about the universal protocol. It supplies a CD-ROM featuring best practice techniques, a copy of the universal protocol with a pocket reference card, a list of frequently asked questions about the universal protocol with answers, and a sample policy template that facilities can adapt and customize.

“Rather than a culture of blame, we should applaud positive behaviors that can reduce the risk of error,” Seifert says. “Instead of a ‘near miss,’ we should say, ‘good catch.’ This is an important distinction.” Rather than preventing errors, the positive spin is patient safety. “Patients expect and deserve safety,” Wein says. “If we can’t provide the correct procedure in a safe environment, why come to the hospital?”

Lorraine Steefel, RN, MSN, CTN, is a senior staff writer for Nursing Spectrum, which publishes NurseWeek.

To view the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery, visit the JCAHOwebsite www.jcaho.org.