Wrong-site surgery was in the news again last month following an incident in Oregon in which the wrong eye of a patient was operated on (Rojas-Burke 2011). In that case the incident occurred despite the performance of the surgical timeout and marking of the correct eye. Apparently the surgeon was at the head of the table and lost orientation and the surgical mark was covered up.
But the OR is not the only place that wrong site events occur. We’ve long known that wrong-site procedures outside the OR are frequent (in our Patient Safety Tip of the Week November 25, 2008 “Stahel 2010) highlighting the continued occurrence of wrong-patient and wrong-site occurrences that had some interesting revelations. The Stahel paper notes how often events such as mislabeling pathology specimens, mixups in medical records or imaging studies or lab reports contributed to the adverse events even inside the OR. That study highlights the importance of the “time-out” in multiple venues of patient care where correct identification of patients and clinical information is critical.” we noted that chest tubes inserted on the wrong side was the most frequent wrong-site occurrence in New York State in the past). In our December 6, 2010 Patient Safety Tip of the Week “ ” we noted a study (
Another new study (Kelly 2011) surveyed emergency departments to determine use of timeout protocols. They found that 13% of the emergency physicians responding were unaware of the existence of formal timeout policies in their emergency departments and only 35% felt they were warranted. Those that did feel timeouts were necessary identified certain procedures (eg. chest tube insertion, lumbar puncture, paracentesis, or procedures using sedation) that should utilize timeouts.
The authors point out that the ED environment might be especially at risk for wrong-patient, wrong-site procedures because of multiple factors (time pressures, multiple providers, multiple handoffs, etc.). But they also note some of the reasons that ED physicians may feel they don’t need timeouts. They note the fact that most ED patients are alert and have injuries that are physically evident (eg lacerations) as major reasons some providers do not feel their patients are at risk. They also note that, compared to procedures done in the OR where several weeks may go by between scheduling and the actual procedure, those done in the ER are usually done promptly, theoretically reducing the time interval for confusion to occur. And the same physician who evaluates the patient is likely to perform the procedure. Some also felt that the presence of family members might help reduce the likelihood of such incidents. Though that reasoning may be prevalent in ED’s, it obviously does not make the ED a safe environment from the perspective of wrong-patient, wrong-site procedures. You still have many of the same factors that contribute to wrong-site surgery in the OR. For example, imaging studies may have mislabeled laterality or the provider may simply put up the image backwards (or have the image on the wrong patient). And not all ED patients are alert and cooperative enough or mentally competent enough to assist with correct identification of sites for procedures. And not all injuries have external markers of injury (eg. not all fractures may be externally apparent). Similarly, even family members may provide erroneous information regarding laterality. And there may have been a change of shift where a new team may now be performing the procedure on the patient. And to that list we’d add the ever present risk of interruptions and distractions in the ED (see our March 8, 2011 Patient Safety Tip of the Week “Yes, Physicians Get Interrupted Too!”). So clearly there are lots of reasons for providers in the ED setting to be using timeouts before performing procedures.
Speaking of imaging procedures, the Pennsylvania Patient Safety Authority (PPSA) has an article on Universal Protocol in radiology services in their most recent issue of the Pennsylvania Patient Safety Advisory. They note the many errors that may take place on the ordering and scheduling side. These include things like transcription errors (where the physician is not directly entering the order into a computer him/herself), choosing the wrong patient or wrong study from a dropdown list, or ordering the wrong study. They note that mammograms often get confused (screening vs. diagnostic). And failure to note a disparity between reason for the study and the study ordered is common.
But failure to identify the patient correctly is also common. One common mistake is using passively obtained information during patient identification. For example, if you ask “Are you Mr. Brown?”, you might get a yes or no response when the patient did not understand or correctly hear the question. Therefore, you always need to ask the patient to state his/her name and then use a second indentifier as well. That second identifier should never be a location or room number. For example, a patient may have been moved from one room to another in a busy ER to accommodate another patient with higher severity of illness. And inpatients commonly are transferred from room to room. Even many offices have multiple rooms and a patient might get moved from an “exam” room to a “procedure” room.
And if you want to see some scary examples of other ways in which patient identification errors may occur, see ISMP’s March 10, 2011 article “Oops, Sorry, Wrong Patient!”.
For invasive radiological procedures, use of timeouts and the Universal Protocol are clearly indicated. In our June 2010 What’s New in the Patient Safety World column “WHO Checklist for Radiological Interventions” we noted that WHO has come out with a modification of its Surgical Safety Checklist just for radiological procedures. The “WHO Surgical Safety Checklist for Radiological Interventions ONLY”, like its predecessor, has three parts: a sign in, a timeout, and a sign out phase.
The PPSA also has a great toolkit available to help organizations minimize the risk of wrong-patient or wrong-site procedures in radiology.
The PPSA radiology article also has some good recommendations that can be applied to any site where the potential for wrong patient, wrong-site events could happen. They note that in addition to having policies and procedures and training in place, you need to enforce compliance with those. So you need to audit and solicit feedback. You need to empower all your staff to challenge when there is any doubt about the patient, the procedure, the site, etc.and all staff need to communicate well and include “hearback” or “readback” under appropriate circumstances. The PPSA toolkit mentioned above also includes a “Did You ID Me” poster and button that are great tools to get your patients involved in the identification safety process.
And, obviously, share stories about events or near-misses that may have occurred in similar settings. Especially in outpatient settings where wrong-patient, wrong-site incidents are less common, staff may need to hear about such an event that could take place in their setting before they change their culture to “beware that it could happen here, too”.
Recently, researchers and quality improvement personnel at Northwestern University (Barsuk 2011) reported on a project to re-engineer their processes for compliance with Universal Protocol for bedside procedures. They looked at lumbar punctures, thoracenteses and paracenteses done on the medicine services at their facilities. Analyzing their processes, they found that staff were often unaware of Universal Protocol (or perhaps unaware that it was required not just for OR procedures, but for bedside procedures as well) and that nurses were frequently never notified by physicians when their patients were undergoing such procedures. In their redesigned process the physician initiates the process by entering an order via CPOE with an anticipated time. This order would automatically populate the nurse’s alert list and provide the nurse with a timeout form and notice of a procedure-specific supply kit to procure. Only the nurse has a key to those procedure kits. This is a forcing function that forces the physician-nurse communication to take place. The nurse brings the timeout checklist and the kit to the bedside at the specified time and the nurse and physician go through the timeout procedure, which gets documented in the EMR. Compliance with Universal Protocol went from 16% before to 94% after implementation of this redesigned process. Elegant!
In our December 6, 2010 Patient Safety Tip of the Week “ verification procedure should be an active one rather than a passive one and all potentially distracting noncritical activities be suspended during the timeout and verification procedure. It is critical that all questions during the timeout verification procedure be phrased in a manner that requires and active answer. Never should you assume that no answer means concurrence. And all involved should be verifying that they are verifying information from relevant documents, not just second-hand information. Any site marking needs to be clearly visible in the prepped, draped field during the timeout. And all this must take place in an environment where all staff are encouraged to speak up and voice any concerns. If there are any concerns, the person performing the procedure must resolve those concerns based on primary sources of information to the satisfaction of all team members.” we stressed that the
What about your office(s)? Ask yourself the following questions:
Don’t make the mistake of thinking “that’ll never happen to us”. Any setting in which procedures occur is at risk for wrong-patient, wrong-site events. Be proactive. Look at all your sites, assess your potential vulnerabilities, and institute the protections you need to keep your patients safe!
Some of our prior columns related to wrong-site surgery:
Patient Safety Tip of the Week columns:
September 23, 2008 “”
June 5, 2007 “ ”
March 11, 2008 “Lessons from Ophthalmology”
September 14, 2010 “ ”
November 25, 2008 “Wrong-Site Neurosurgery”
January 19, 2010 “Timeouts and Safe Surgery”
June 8, 2010 “Surgical Safety Checklist for Cataract Surgery”
December 6, 2010 “ ”
What’s New in the Patient Safety World columns:
July 2007 “ ”
Rojas-Burke J. Wrong body part, wrong patient surgeries continue despite new procedures.OregonLive.com May 25, 2011
Stahel PF, Sabel AL, Victoroff MS, et al. Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era. Analysis of a Prospective Database of Physician Self-reported Occurrences. Arch Surg. 2010; 145(10): 978-984
Kelly JJ, Farley H, O'Cain C, et al. A Survey of the Use of Time-Out Protocols in Emergency Medicine. The Joint Commission Journal on Quality and Patient Safety 2011; 37(6): 285-288
Pennsylvania Patient Safety Authority. Applying the Universal Protocol to Improve Patient Safety in Radiology Services. Pennsylvania Patient Safety Advisory 2011; 8(2): 63-69
Did You ID Me
Institute for Safe Medication Practices (ISMP). Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside. ISMP Medication Safety Alert.. Acute Care Edition. March 10, 2011
NPSA (UK). WHO Surgical Safety Checklist: for radiological interventions only. April 2010
Barsuk JH Brake H, Caprio T, et al. Process Changes to Increase Compliance With the Universal Protocol for Bedside Procedures. Arch Intern Med. 2011; 171(10): 947-949