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Almost Left Behind - Subscribe to Outpatient Surgery Magazine - April 2018

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

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the first letter of their first and last name on the surgical site, and then make an incision through the ink, as if it were a bull's eye. If every surgeon would do that one simple thing every time, the safety experts say there'd be a lot fewer wrong-site surgeries. Sounds simple, right? But every year, U.S. surgeons perform about 2,000 incorrect operations. Perhaps the best known case is one you've probably heard before. Hand and arm surgeon David Ring, MD, PhD, performed a carpal tunnel release instead of a trigger finger release on a 65-year-old female patient. Dr. Ring famously broke the silence that surrounds surgeon errors when he issued a public mea culpa in the Nov. 11, 2010, edition of the New England Journal of Medicine (osmag.net/SG2tvD), sharing in great detail with his fellow docs the missteps that led to his error. Dr. Ring has since lectured and written about wrong-site surgery countless times, along the way becoming, as he puts it, "the poster child for oper- ating on the wrong body part." Dr. Ring was a proponent of the "sign your site" protocol before his wrong-site error. But hospital policy was for a nurse or a surgeon to mark the limb, not the site. In Dr. Ring's wrong-site case, a nurse had marked the correct arm at the wrist, but not the planned incision site on the hand. Dr. Ring gives credence to using checklists and hard-stop time outs. He also has a few rules on site-marking: • The surgeon must make the mark, but only after confirming the indication (appropriateness), affirming the patient's desire for surgery (consent), and verifying the site and the surgery with the patient and on the consent form. • The ink must go where the knife will cut. It should be a bull's-eye that draws the attention of the surgeon and team to the correct side, site and surgery. It cannot go nearby on the limb. 4 2 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • A P R I L 2 0 1 8

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