W
rong-site surgeries occur approxi-
mately 40 times a week in facili-
ties across the U.S. Surgical pro-
fessionals must therefore ask
themselves why these avoidable
errors continue to be an issue despite increased
efforts to correct the problem, and what can be done
to limit or prevent them from happening.
A major issue is that there is no single root cause
of wrong-site surgery. However, the Joint
Commission has noticed common themes during
reviews of incidents, including communication
errors, hand-off errors, confirmation bias and con-
sent that is either unclear, illegible or not specific
enough. For instance, cases where the correct side
or site isn't noted in pre-op paperwork.
One of the most effective ways to eliminate
wrong-site surgery is to follow the long-standing
Universal Protocol, which addresses proven methods
to ensure surgeons make the correct cut during
every case. Make sure the three primary components
of the Universal Protocol are in place at your facility.
• Establish a verification process. Providers
need to understand that each step within the
Universal Protocol is crucial in preventing wrong-
site surgery. Through the targeted solutions tools
that The Joint Commission developed, we closely
looked at wrong-site surgeries and found that the
O C T O B E R 2 0 2 0
• O U T P A T I E N T S U R G E R Y . N E T • 11
Edward Pollak, MD | Oakbrook Terrace, Ill.
Keys to Site-Marking Success
Consistent protocols and a transparent work
environment will prevent wrong-site surgeries at your facility.
SIGN YOUR SITE Patient safety experts recommend surgeons mark only the correct surgical site — not where they shouldn't cut.
Pamela
Bevelhymer,
RN,
BSN,
CNOR
