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N E V E R
E V E N T S
From October 2009 to October 2010, 31 wrong-site surgical events were reported in Minnesota. More than 60% of those wrong-site
procedures occurred on the wrong side — left rather than right, or vice versa — and nearly all could be attributed to breakdowns in basic best practices. The site mark wasn't visualized. Source documents weren't referenced. The surgeon said, "I agree," rather than independently verifying the procedure and site. And, in a surprisingly high number of cases, no process was in place for site-marking and conducting a time out.
These sorts of oversights — most of them seemingly insignificant at the time — happen every day in ORs nationwide, despite years of the Universal Protocol and sentinel event status for wrong events. We know because wrong events are still happening. Here's a look at a few from our database (for legal reasons, they're composites, but the elements are all real) and what could have been done to prevent them.
Case No. 1: Wrong implant
The patient was seen in the surgeon's clinic for removal of a cataract and replacement of the lens in the right eye. The patient and surgeon agreed that the patient's vision wouldn't be corrected to 20/20 because the patient never had 20/20 vision and didn't want this change. The patient consented to correction to less than 20/20, and the surgery was scheduled. The physician ticked the wrong box on the documentation, though, and the surgery center ordered the wrong implant. The physician ended up implanting a lens in the right eye that corrected vision to 20/20.
This isn't a case where the OR time out could have helped — the documentation matched the expected procedure and the supplies in the room — but asking the right questions would have. The pre-op phone call should have verified the implant type in addition to the
