Outpatient Surgery Magazine

Special Outpatient Surgery Edition - Staff & Patient Safety - October 2017

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

Issue link: http://magazine.outpatientsurgery.net/i/880034

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6 S U P P L E M E N T T O O U T P A T I E N T S U R G E R Y M A G A Z I N E O C T O B E R 2 0 1 7 O f the 3 wrong-site surgeries we had in 6 years at my former hospital, one in particular illus- trates how even the slightest deviation from policy can create a crack large enough for a never event to slip through. It was a right knee replacement. Or at least it was supposed to be. The surgeon marked the right (right, as in correct) knee in pre-op, but he wrote his initials low on the leg, not on the surgical site. Once the patient was prepped and draped, you couldn't see the site marking. Two seemingly minor oversights — the surgeon's initials not being over (or as close as possible to) the incision site and not being visible after the patient has been draped — would set into Lessons From 3 Wrong-Site Surgeries Focus on what really happened, not what's supposed to happen. Steven Wentworth, RN, CNOR, BSN, MBA | Gainesville, Fla. NEVER EVENT? It's surprisingly easy for even the most well-intentioned surgical team to operate on the wrong body part. Pamela Bevelhymer, RN, BSN, CNOR

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