How to Help Prevent Wrong Site Surgeries

January 4, 2012

Jesse Gaul, a 3 year old boy, went to the hospital for a quick and simple surgery to repair his lazy eye. The two years leading up to the surgery his parents, Tasha Gaul and Dale Matlock, took Jesse to see Dr. Shawn Goodman. They felt confident the surgery would run smooth and felt confident in their surgeon up until the operating room. To their shock, the operation began on the wrong eye. Referred to as a "wrong site" surgery.

Unfortunately this is occurring too often, and is completely avoidable. According to Gaul, Goodman told her, "Frankly, I lost my sense of direction, and by the time I realized it was the left eye, I was almost done." Dr. Goodman had to then complete the procedure on the correct site.

According to the CNN report on a 2006 study looking at the frequency of surgical errors in the United States, it was found that as many as 2,500 mistakes took place during surgery. These surgeries took place on the wrong body part or the wrong patient. That's about seven per day.

When Dr. Kenneth Kizer heard of what happened to Jesse his first thought was "Not another one…it's serious, it's preventable, and it should never happen," he said. Kizer is the former CEO of the safety advocacy group National Quality Forum. He acknowledges that efforts to prevent these types of surgical errors have taken place, but there is still room for improvement.

It has been suggested by the patient safety advocates that hospitals use a checklist as recommended by the American Academy of Ophthalmology, they supply a checklist for before, during, and after a procedure on the eye to prevent wrong site surgeries. One of the most important processes to prevent this type of occurrence is to make sure everyone is communicating. We found these 6 steps from a article on CNN that are recommended to ensure a greater chance your surgery is completed properly:

  1. Ask, "What are you going to do to ensure that you don't operate on the wrong site?" Kizer says that asking this question explicitly puts the concern on the doctor's radar. "Patients have to be aggressive sometimes," Kizer said. Also, if someone new is seeing you, this question may help to remind them to review your records and clarify one more time.
  2. Request a "time-out" just before anesthesia. The Joint Commission's Universal Protocol recommends that the operative team take what is called a time-out right before surgery. That's a time when all relevant members of the surgical team stop and communicate to ensure they are all in agreement on what's about to happen.
  3. Say: "My name is John Smith, and my birthday is January 21, 1976." Patient advocates say to make sure your name is double- and triple-checked and that prior to surgery, whether you're speaking with the surgeon, the anesthetist or the nurse, make sure everyone involved in your care knows exactly who you are.
  4. Don't rush through the informed consent form. Patients fill out a consent form, which details what specifically is being done and the possible risks and complications. Kizer says sometimes patients glaze over the details because they don't like to hear about the horrible things that can happen.
  5. Make sure your doctor initials your site. The protocol may vary from hospital to hospital, but the bottom line is that patients should make sure the surgeon clearly marks the proper surgical site before you leave the pre-op area.
  6. Trust your gut. Jesse Matlock's parents said they initially had a bad feeling about how the surgery would go when, on the morning of the procedure, one of the surgical nurses mentioned paperwork that said the little boy would need surgery on one or both eyes. Gaul says her fears were allayed when Goodman, in the presence of other members of the surgical team, indicated the proper incision site by drawing several marks, including one about the size of a quarter on the skin above Jesse's right eye.

Diane Pinakiewicz, president of the National Patient Safety Foundation, says patients should consider themselves critical members of the health-care team.

"Patient involvement is one of the keys. It's imperative that they be proactive," she said.