6 S U P P L E M E N T T O O U T P A T I E N T S U R G E R Y M A G A Z I N E O C T O B E R 2 0 1 7
O
f the 3 wrong-site surgeries we
had in 6 years at my former hospital, one in particular illus-
trates how even the slightest deviation from policy can create
a crack large enough for a never event to slip through.
It was a right knee replacement.
Or at least it was supposed to be.
The surgeon marked the right (right, as in correct) knee in pre-op, but he wrote
his initials low on the leg, not on the surgical site. Once the patient was prepped
and draped, you couldn't see the site marking. Two seemingly minor oversights
— the surgeon's initials not being over (or as close as possible to) the incision
site and not being visible after the patient has been draped — would set into
Lessons From 3 Wrong-Site Surgeries
Focus on what really happened, not what's supposed to happen.
Steven Wentworth, RN, CNOR, BSN, MBA | Gainesville, Fla.
NEVER EVENT? It's surprisingly easy for
even the most well-intentioned surgical
team to operate on the wrong body part.
Pamela
Bevelhymer,
RN,
BSN,
CNOR