Reduce Medical Errors | Prevent Wrong Site Surgery |

Wrong site or wrong side surgery is vary rare. But if it occurs, it can ruin the surgeon's career.

What about the patient who was operated on the wrong site or side. It will be tremendously devastating.

It is better to prevent this from happening. How? And what is the best way?

I believe that every hospital in the United States must have some kind of protocol or guideline to prevent wrong site or wrong side surgery. One of the most common component of the protocol is to mark the surgical site or side in the operating room, before the start of the operation.

The protocols that I have seen or involved with were all excellent to prevent wrong side surgery but, in my opinion, contained one potential weakness. Let me explain by using a fictitious case to illustrate my point.

An elderly patient with history of mild cognitive impairment, with right inguinal hernia, sees his surgeon today. The diagnosis was confirmed. A right inguinal hernia is scheduled to be done three weeks later. This surgeon is a world renowned hernia surgeon. He usually will line up four or five hernia cases in a row.

On the fateful day, our patient above, woke up in the recovery room with a surgical wound and bandage on the left groin. The patient was supposed to have spinal anesthesia but it was not quite effective. The anesthesiologist had to give him intravenous sedation.

How could this wrong site surgery happened when the surgeon, the operating room(OR) nurses and other personnel all agree that the left inguinal hernia was was the the correct side? The OR schedule showed left inguinal hernia repair. The surgical consent was for left inguinal hernia repair. The surgeon marked the left side correctly. So it seemed.

Here is theoretically what could have happened.

The patient really did have right inguinal hernia but the surgeon wrote in the chart as left. If the mistake was not corrected here, a left inguinal hernia will be scheduled and the wrong side operation could happened. Any alert patient could have prevented this serious surgical error at the time of signing the consent. If he missed this opportunity, he would have another chance when the surgical site was being marked.

But our patient above was elderly and cognitively impaired and our busy and famous surgeon had performed four hernia repairs in one day, two left and two right.

How can we prevent this extremely rare but very serious mistake?

In my opinion, we should be able to prevent wrong site or side surgery 100 percent by following the following protocol strictly. This protocol will be created by the OR committee of a hospital.

1. Create a printed diagram of a full length human figure face-up on a standard sheet of paper . We will call this "Surgical Site Marking Sheet(SSMS)"

2. The surgeon will mark the surgical site on the SSMS, immediately after the patient was examined,right there in the office examination room, corresponding to the site written on the progress note in the medical chart.

3. The patient will be given a copy of the marked SSMS and instructed to bring it to the hospital on the day of surgery.

4. The surgeon will call the OR scheduler to schedule the operation AND fax the marked SSMS to the OR scheduler immediately.

5. No surgical procedure which requires a side or site will be put on the OR schedule without the marked SSMS.

6. The marked SSMS will be a permanent part of the medical record.

7. The procedure can not be started without the marked SSMS in the medical record. If the OR scheduler lost the Marked SSMS, obtain the copy the marked SSMS from the patient. If the patient forgets to bring it to the hospital, obtain a faxed copy from the surgeon's office.

8. The actual surgical site marking on the patient still can be done in the OR.

The above protocol is written in such a way that any patient will understand the process.

Currently, the SSMS protocol, with some variation from above, has been implemented in several hospitals in a Health System in Michigan. I can also say that I was involved extensively in it's implementation, of which the story will be told in a future post.