• If there is not ink
where the consent
and the team say the
cut should be made,
the surgery should
not proceed.
"But in a busy OR, if
a surgeon doesn't put
the ink on the
absolute exact spot
where he is going to
cut through, people
will often just accept
that variation," says
Dr. Ring. "It is surpris-
ing how hard it can
be to speak up."
In this way, a safety
feature is compro-
mised, because of the
natural tendency of
people not to express a concern that could be dismissed as petty.
Dr. Ring's final words to his colleagues in the New England
Journal of Medicine dispel that notion: "I hope that none of you
ever have to go through what my patient and I went through. I no
longer see these protocols as a burden. That is the lesson."
More practical pearls
Human error is reducible, but not unavoidable. One study claims com-
munication failures were the root cause of 70% of wrong-site surger-
4 4 • 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
• WASH AWAY? Use an indelible marker to mark the site to ensure that the pre-
op skin prep solution doesn't wash away the mark.
Pamela
Bevelhymer,
RN,
BSN,
CNOR
