June 2003 Bulletin

AAOS co-sponsors summit on wrong-site surgery

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), its corporate members and the AAOS focused attention on wrong-site surgery during a special one-day summit meeting they co-sponsored in Chicago on May 9, 2003. Senior leaders of more than 30 other professional groups relating to the surgical process also participated. The intended purpose of the meeting was to reach consensus on a universal protocol for the prevention of wrong-site surgery.

In addition to JCAHO and the AAOS, other participating groups included: Agency for Healthcare Research and Quality, American Medical Association, American Hospital Association, American College of Physicians, the American College of Surgeons, American Academy of Ophthalmology, American Academy of Pediatrics, American Association of Nurse Anesthetists, American Association of Oral and Maxillofacial Surgeons, American College of Chest Physicians, American College of Foot and Ankle Surgeons, American College of Obstetricians and Gynecologists, American Association of Eye and Ear Hospitals, American Dental Association, National Patient Safety Foundation, North American Spine Society, American Nurses Association and Association of American Medical Colleges.

AAOS was represented by President James H. Herndon, MD; David A. Wong, MD, chair, Patient Safety Committee; William W. Tipton, Jr., MD, director of Medical Affairs; Kristin Olds Glavin, associate general counsel; Susan Nowicki, APR, director of communications and Sandra Gordon, director of public education and media relations.

The summit examined several aspects of wrong-site surgery, the performance of wrong procedures on patients and the performance of surgery on the wrong patient. The topics discussed included:

Protocol specifics identified

Attendees agreed that a universal protocol for eliminating wrong-site, wrong-procedure, wrong-patient surgery would be helpful, and identified many of the specifics that should be included:

  1. Site marking is necessary for surgeries that involve:
  2. a. Right/left distinctions

    b. Multiple structures (such as fingers or toes)

    c. Multiple structural levels (such as vertebrae)

  3. Site marking should be done with an "indelible" marker that will not wash off with the usual skin preparations prior to surgery.
  4. Site marks should be done in a place that leaves them visible after the patient is prepped and draped for surgery.
  5. Marking non-operative sites (such as "No" on the non-operative leg) should not be done.
  6. Stick-on labels are not an acceptable substitute for marking directly on the skin.

Participants also agreed that taking a moment in the operating room before the surgery begins to verify the patient’s name, procedure, and site of procedure would be one way to reduce the number of wrong-patient/wrong-procedure surgeries.

When site-marking isn’t necessary

In addition, participants agreed that some surgeries do not require site marking. These surgeries may include midline sternotomies, Cesarean sections, laparotomy and laparoscopy, cardiac catherterization procedures, other interventional procedures without a predetermined insertion site, procedures done through or immediately adjacent to a natural body orifice and other situations in which marking the site would be impossible or impractical. Site marking is not required for routine "minor" procedures such as venipuncture, peripheral IV line placement, NG tube insertion or Foley catheter insertion.

Site marking for bedside procedures is not required if the practitioner performing the procedure remains with the patient continuously from the time the decision is made and consent is obtained to do the procedure up to the time of the procedure itself. However, if the practitioner leaves the patient for any amount of time, and the procedure involves right/left distinctions or multiple structures, the practitioner should mark the site before leaving the patient.

Next steps

This year (2003) JCAHO adopted the elimination of wrong-site, wrong-patient, wrong-procedure surgery as one of its National Patient Safety Goals. It recommended that there be a preoperative verification process, such as a checklist, to confirm that appropriate documents such as medical records and imaging studies are available. It also endorsed the AAOS idea of marking the surgical site and involving the patient in the marking process.

Despite these efforts, JCAHO continues to receive five to eight new reports of wrong-site surgery every month. The majority of these involve a breakdown in communication between surgical team members and the patient and family, but policy issues, such as not requiring marking or verification of the site, were also noted as contributing causes.

Based on summit discussions, JCAHO has prepared a draft set of principles and a protocol that have been distributed to Summit participants for comment. These documents will be presented to the JCAHO Board of Commissioners for approval at its July meeting. A follow-up national symposium on wrong-site surgery and a universal protocol is being planned for the fall.

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