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The third case was an arthrectomy. The confusion arose because the vascular
surgeon marked the entry point (right), not the surgical site (left). The surgeon
entered through the right femoral artery, but ended up removing plaque from the
left leg. A day later the referring physician asked: "Hey, weren't you supposed to
do the right leg?" We changed the site-marking policy for such cases so that the
surgeon marks the operative leg, not the entry point.
Culture will eat strategy for lunch
Wrong-site surgery occurs either because your process is broken or because
your surgical team deliberately chooses not to follow your process. You can
have the best surgical safety policy around, but if your staff is afraid to speak up
when they see something that's not quite right, it's all for naught. Empower your
staff to stop the physician in the middle of a case. He might get a little angry, but
ensuring safety is paramount. And if you find that you have to refine your safe
surgery policy, don't do so in a vacuum. Consult the people who are on the front
lines of surgery.
OSM
Mr. Wentworth (steven.wentworth@hcahealthcare.com)
is currently director of surgical services at North Florida
Regional Medical Center in Gainesville, Fla.
