defect is often upstream — even in the office that
produced the consent form. Errors can occur in
the OR if notes from surgeons' offices are incor-
rect or include last-minute changes, or if the order
of the patients in the OR schedule changes without
the care team being notified. Put a process in place
to confirm the correct patient, procedure and sur-
gical site are noted on consent forms, the surgical
schedule and pre-op paperwork before patients
arrive for surgery.
• Mark the surgical site. The area where we see
the most variability is during the time-out process
because it's highly dependent on workflow (more
on that later), but there are also inconsistencies in
terms of who marks the site and
how they do it.
It's imperative to establish
standards that are clear and
unambiguous. However, the vari-
ability surrounding site marking
can be problematic. For example,
if certain team members are used
to one convention for site-mark-
ing, but then move to a different
facility where the standards are
completely different, there is
more room for error. Additionally,
a surgeon might mark the surgical
site with their initials, with a
check mark or by circling the area
— it really comes down to their
facility's policy. The most com-
mon policy requires surgeons to
mark sites with their initials.
There are clear recommenda-
tions from patient safety experts
that surgeons should never write
"no" on the incorrect site. They
should mark only the site they're
going to work on because mark-
ing another area could create
unnecessary confusion.
Yes, it certainly would be easi-
er if there were a national consen-
sus surrounding site-marking.
Still, you can greatly reduce
potential issues by establishing a
single process that is well-known
and understood by every surgeon
and staff member — and making
sure it's consistently enforced.
Site-marking should occur in
pre-op holding and should be
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Putting protocols in place to prevent wrong-site surgery might
require a few organizational modifications. Start with these
essential steps.
• Encourage organizational leadership. Promote behaviors
that support a culture of safety and teamwork, which includes
engagement of the whole team — including the patient and the
family — and appropriate staffing and workflow.
• Promote staff engagement. Establish "good catch" pro-
grams and an anonymous incident reporting system where staff
are rewarded for entering unsafe conditions, which could
include a time-out when the team wasn't engaged in the
process. These methods are not meant to be used as a punitive
way to get colleagues in trouble, but rather to coach staff mem-
bers and use an incident as a moment of learning before it
becomes a problem.
• Be transparent. Transparency should be a key value within
a healthcare organization. Staff should be encouraged to speak
up anytime they witness an error or an unsafe condition.
—Edward Pollak, MD
HUDDLE UP Promote behaviors that support a culture of safety and teamwork.
PROCESS IMPROVEMENT
Confirm the Correct Site Every Time
