O C T O B E R 2 0 1 7 O U T P A T I E N TS U R G E R Y. N E T 7
motion a chain of events
that would lead to the sur-
geon cutting into the
wrong knee.
Making matters worse,
the circulator was dis-
tracted, looking ahead to
the next case in the next
room, instead of focusing
her attention on the here
and now. Maybe that's
why nobody noticed that
the team had mistakenly prepped and draped the left
leg, not even during the time out, a half-hearted exer-
cise not everybody paid attention to or participated in. Fortunately, soon after the
surgeon made his incision on the wrong knee, an astute anesthesiologist spoke
up: "Excuse me, but aren't we supposed to be doing the right leg?"
How did he know? Because the surgeon always stands on the opposite side of
the leg on which he's operating. This time, however, he was standing on the
patient's right side and the anesthesiologist was pretty sure we were operating
on the right knee. Even though we caught the error before the surgeon proceed-
ed with the case, technically this went down as a wrong-site surgery because
we'd made an incision on the wrong knee. Would the surgeon have replaced the
wrong knee had the anesthesiologist not spoken up? Hard to say for certain, but
let's just say we're glad we didn't find out.
The surgeon closed the wound and stepped out of the OR to discuss the error
with the patient's family. Even though some might argue that this was a near
miss, it's critically important to be honest and forthright and by all means to
apologize when an error occurs. "We made a mistake and we're so sorry." You
CALLING TIME During a time out, all
activity must cease and everyone in the
room must give their undivided attention
to the person leading the time out.
Pamela
Bevelhymer,
RN,
BSN,
CNOR
