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Therapeutic Nursing Interventions for Reducing Wrong-Site Surgery

Mary-Margaret Whitten

Old Dominion University


Therapeutic Nursing Interventions for Reducing Wrong-Site Surgery

Wrong-site surgery is the action of performing surgery at the wrong site or laterality of

the body, performing the wrong procedure, or performing a surgery on the wrong patient (Tena,

League & Brennan, 2018). Despite efforts by the Joint Commission (JHCAO), the World Health

Organization (WHO), and other professional organizations such as the Association of peri-

Operative Registered Nurses (AORN), to develop standardized processes and protocols in efforts

to reduce the risk of human error to cause a patient harm (Collins et al., 2014) mistakes are still

being made, and wrong site surgeries are still being performed.

Chippenham Medical Center in Richmond, VA is a level I trauma center, with 16 suite

operating room (OR) that is struggling to keep its patients safe while undergoing surgery, due to

the lack safety precautions in place, such as the use of a surgical safety checklist, to safeguard

from mistakes reaching the patient. The hospital is situated in the heart of a working-class, low

income part of the city. Limited resources prohibit residents from receiving primary or

preventive care. Therefore, the patient population is sicker, has more comorbidities, and higher

acuity levels on admission than patients found in surrounding area hospitals.

Even the physical layout of the OR presents safety issues, as it is spread across 3 floors

and two buildings. The Main OR is on floors one and two. The first floor has 8 ORs adjacent to

the same day surgery pre-op holding area, and the post-anesthesia care unit (PACU) as well as

the central supply room and sterile core. There are an additional four OR rooms that can be

reached via an elevator inside the sterile core that delivers passengers to the second floor about 5

feet on the outside of the red line, indicating only authorized personnel beyond that point. The

ability to access the sterile core via an elevator that originates outside of the operating room
demonstrates additional disregard of safety protocols and policies. The direct connection of

sterile and unsterile areas, as well as the ability of non-authorized personnel to accidentally enter

the area compromises the sterility of the entire core, increasing risk for surgical site infections in

every operation performed using the instruments and supplies stored within it.

The hospital is situated in the heart of a working-class, low income part of the city.

Limited resources prohibit residents from receiving primary or preventive care. Therefore, the

patient population is sicker, has more comorbidities, and higher acuity levels on admission than

patients found in surrounding area hospitals. The OR does not employ enough nurses to supply

the patient need for surgery. The staff is a close-knit, competent team, but they are exhausted due

to working long hours and being on-call far too often to achieve any sort of work-life balance.

Morale is low and stress levels are high. Recent leadership changes, following poor department

management, has left the staff frustrated, stressed, tired and with an unrecognized decrease in

their ability to care for (and possibly about) their patients. Staff are desensitized to the inherent

high-risk environment that is the OR, and this leads to omission of safety precautions, such as the

use of a surgical safety checklist, to keep the patients and staff safe.

Clinical Problem

Clinically, Chippenham Medical Center falls behind its competition in the area of wrong-

site surgeries. Recently, a wrong site surgery reached the patient when a notoriously quick

orthopedic surgeon implanted the wrong knee during what should have been a routine total knee

arthroplasty. The mistake was allowed to continue until the cuts had been made in the patients

bones to accommodate the implant. The sales rep caught the error when they began trialing the

implants and the new joint would not sit flush as it was made to fit the anatomic opposite. That’s

when he spoke up telling the team “oh no I set you up for a right side. Sorry I had on my
paperwork that this was a right. What does the consent say?” After talking with the patient’s

family, the doctor proceeded to give the man bilateral knee implants, making his recovery much

longer and harder. Not to mention he now has two implanted knees and he only needed one.

Reason I choose this clinical problem.

The day the WSS occurred, I couldn’t believe this “never” or “sentinel event” had not

only occurred, but it had both reached and harmed a patient. Until it happened, I would never

have believed that wrong-site surgeries are a real threat to patient safety. Much less was this

something that could happen in my hospital, to my competent coworkers. This clinical problem

hits close to home in a way that I never thought possible. Until recently, a WSS was something

of the past, not a modern-day problem to be solved. I was one of the many health care providers

blissfully ignorant to and unaware of the continued prevalence of WSS. With the proven

interventions we have to prevent WSS and protect patient safety, how did everyone involved, fail

catch this before it was too late?

Why is this problem present in the clinical practice setting?

The culture of the OR continues to allow preventable errors to reach and cause harm to

the patient. For example, the OR does not employ enough nurses to supply the patient need for

surgery. The nursing shortage means there are only five full time nurses who take call resulting

in minimum call requirements of 125 hours a month or more. Temporary agency nurses barely

fill the “warm body” requirement because by the time they start to get acclimated and are

independently useful, they are off to the next assignment and the cycle starts over. The staff is a

close-knit and competent team, but they are exhausted from working long hours and no real

work-life balance. Morale is low and stress levels are high. Recent leadership changes, following

poor department management, has left the staff frustrated, stressed, tired and with an
unrecognized decrease in their ability to care for (and possibly about) their patients. Staff seems

desensitized to the inherent high-risk environment that is the OR, leading to omission of safety

precautions and nursing interventions, such as the use of a surgical safety checklist, to keep the

patients safe and the staff prepared for the worst.

This does not excuse nurses from deviating from the evidence-based standards of care,

nor the policies and protocols laid out by professional organizations and hospital systems to

guide nursing practice. On my unit the staff is constantly being pushed to improve their

“metrics.” Each morning the focus is on time starts, fast turnover times and rushing to get the

doctors into and out of the operating room as fast as possible. Patient safety is barely a

consideration to many of the staff even though these patients are going to be on the operating

room table, possibly for hours, without any position aides to prevent pressure ulcers and skin

breakdown, but it saves a few minutes and time is money. The collective focus is on “getting it

done” not necessarily “getting it done right.”

Current Clinical Practice

The current clinical practice, a result of formal mechanisms driving perioperative nursing

care at Chippenham Medical Center adheres to the 2009 WHO recommendations for use of a

surgical safety checklist in all operative procedures as a part of the fulfillment of the universal

protocol. Because most errors related to safety concerns can be attributed to inadequate

communication and poor teamwork, the Surgical Safety Checklist drafted by the WHO in 2007

outlined a three-part checklist that requires interruption of anesthesia course to allow for three

specifically timed briefings (Fudickar, Horle, Wiltfang, & Bein, 2012). Another formal

mechanism present is outlined in the Joint Commission’s universal protocol, a standardized

approach to prevent wrong-site surgeries to include pre-op verification using two patient
identifiers, before the patient is sedated, marking of the surgical site and the institution of the

time-out prior to beginning surgery. Formal mechanisms to prevent wrong site surgery as

outlined in the AORN perioperative standards and recommended practices (2013) as it relates to

prevention of patient harm. The “standards of perioperative nursing provide a mechanism to

delineate the responsibilities of RNs engaged in practice in the perioperative setting” (AORN,


Informal mechanisms related to the universal protocol

While all perioperative nurses understand the need for the universal protocol’s “time out”

there are times when the timeout may be performed in an improper or abbreviated form. If the

use of the surgical safety checklist is to perform as a fail-safe measure to preventing wrong-site

surgeries, all components must be used properly (Collins et al., 2014). The nurse performing the

time out during the WSS at Chippenham did not follow hospital protocol. It is imperative that the

timeout be performed using the surgical safety checklist, while verifying that the consent

matches what you are set up to do, and that everyone in the room is engaged during each step of

the process, or the system cannot be relied on the effectively prevent wrong site surgeries. The

nurse in this situation was rushing to hook up all the equipment in the room to get the surgery

started, when the surgeon called for the time out. In the interest of time the nurse performed the

timeout from memory, only glancing at her notes briefly during the timeout. By this point, the

doctor who was operating in two adjacent operating rooms on this particular day, working his

way back and forth between the two rooms. He would operate in one room while the surgical

assistant finished closing the previous patient’s wounds, and quickly cleaned and turned over the

room to expedite the next surgery. If the staff was moving at the pace the doctor preferred, he

would just be walking out of one room as the surgical assistant finishes draping the patient so he
can stop by the scrub sink and start all over again. Typically, the doctor walked into the room

with hands still dripping with soapy water from the scrub sink ready for his gown, gloves, and

the time-out. When the doctor arrived, the day of the WSS, the leg was already prepped and

draped. By the time the nurse was performing her time-out from memory, the final check before

the incision is made, no one was paying attention to her anyways and no one noticed she was not

reading from the consent.

Rationale for discrepancies between the formal and informal mechanisms

Deviation from the evidence-based standards of care, and/or the policies and protocols

laid out by the AORN to guide perioperative nursing practice will lead to errors (Conrardy,

Brenek, & Myers, 2010). Every day at Chippenham is an uphill battle for the staff. They are

suffering from physical and mental exhaustion, and it is burning them out. Many of the older

employees are waiting out their retirement and they lack the motivation to work hard. The

Chippenham is fast paced, bustling with “activity, numerous distractions, a hierarchical reporting

structure, advanced technology, and complex equipment, all of which can affect health care

professionals, making them prone to making errors” (Collins et al., 2014).

Corners are getting cut. Precautions that are usually commonplace taken to protect

patient’s skin, such as using egg crate to pad boney prominences and any lines or drains when

positioning the patient to avoid skin breakdown, get forgotten. It is the responsibility of the

perioperative nurse to advocate for the patient and keep him free of harm. On my unit, this

important step is often being skipped due to limited resources (i.e. someone forgot to order the

egg crate) limited time to gather supplies from storage locations across 3 floors of the large

hospital, and limited time for pre-op preparations from the doctor because he has been waiting,
not so patiently, for several hours to get operating room time due to the lack of staff to run the


Nursing Interventions and Literature Review

The AORN publishes its “Perioperative Standards and Recommended Practices for

Inpatient and Ambulatory Settings” to serves as a comprehensive guidance document “that

reflects the RN’s scope of professional responsibility and provide essential information for the

delivery of safe perioperative patient care and a safe work environment” (AORN, 2013). The

AORN recommended practices represent “what is believed to be the optimal and achievable

perioperative nursing practice and are based on the highest level of evidence available” (2013).

When sentinel events occur, there is often no one singular mistake that directly influences

its occurance. Often it is a combination of many smaller events or mistakes that synergize to

create one big mistake. The use of a surgical safety check list is a simple way to avoid wrong-site

surgery caused by human error. To be effective at preventing mistakes the entire surgical team

must respect and participate in the process fully. The adoption of the checklist alone is not

enough to stop the various process failures that continue to occur because of the departure from

the recommended procedures. My first intervention will be to implement a surgical safety

checklist. We currently don’t have one and having come from a facility that placed a printed

copy of the WHO surgical safety check list on every chart when patients arrived for surgery, I

believe it has the both the ability to improve safety and foster a sense of teamwork (Benham et

al., 2016). Studies show that checklists have the ability to identify problems early, preventing

surgery delays, suggesting that the use of a checklist can prevent patient harm, wrong site

surgeries, build comradery between teams while improving operating room flow, increasing OR

efficiency and ultimately improving patient outcomes (Benham et al., 2016).

My second intervention will be to require the surgeon to initiate and lead the timeout

utilizing a checklist. I will require the doctor to initiate a pre-operative verification before the

time out and then performing the final time out after the patient is prepped and draped. Having

the final time out after prepping and draping allows the surgical team to verify the site marking

during the time out (AORN, 2019). The entire team will participate in confirming surgical site,

laterality, procedure and then the team will introduce themselves and state their role. Currently

the nurse calls for the time out and is often ignored, making the timeout and surgical checklist

and unreliable check. According to the Joint Commission (2019) between 2015 and 2018 the

incidence of 440 wrong-site surgeries were reported to the sentinel event data. Almost 30% of

the 440 WSS could be attributed to incomplete or incorrectly performed surgical timeout,

indicating a need for continued efforts and education into standardizing and conducing effective

time outs to prevent human errors (Croke, 2017).

My third intervention will include clustering like surgeries together. For example, for

orthopedic surgeons with two block days will spend one block day doing right joints and one day

doing left joints. This should decrease the likelihood of an error without any additional work on

the team. This has been done in other local facilities with good results and I am eager to try at



Implementation of the processes needed to ensure adherence to the universal protocol

requires a multidisciplinary team approach consisting of active staff and patient participation,

leadership by a supportive hospital administration and an open line of communication between

all involved (AORN, 2010). As regulatory bodies and the Joint Commission on Accreditation of

Healthcare Organizations (JCAHO) focus their efforts on patient safety and reducing the errors
that reach and potentially harm the patient. Based on evidence-based practices detailed by the

AORN, perioperative nurses have the ability to minimize error and reduce wrong-site surgeries.

The most important part of implementing the WHO check list is that the list is not merely

something to check off, or mindlessly recite but it is a tool to improve communication and

promote a culture of safety within the operating room, leading to reduced human error resulting

in wrong-site surgeries (Fudickar, 2012).


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