At the Becker's ASC 21st Annual Meeting — The Business and Operations of ASCs, Oct. 23 to 25, in Chicago, Sandra Jones, MBA, CASC, LHRM, FHFMA, senior vice president and COO of ASD Management, discussed the unfortunate but recurrent situation of wrong-site surgery in ambulatory surgery centers.
Ms. Jones opened the session by discussing a number of case studies on wrong-site surgery. In one situation, the patient was due to receive an ankle anesthesia block and was given the block in the wrong ankle. While the anesthesiologist had marked the correct ankle, he or she then left the room to get the medication. While out of the room, the patient had been flipped in preparation for the procedure, and the patient had crossed his legs, causing the mark to rub off on the other ankle. The anesthesiologist was just about to begin injecting when the patient brought attention to the fact that it was the wrong ankle.
"The situation could have been prevented if the anesthesiologist had called for a time-out before beginning to inject or if the anesthesiologist had kept the medication ready in the room," said Ms. Jones. "Also, the patient could have been flipped before the anesthesiologist had made the mark."
In another case, a 17-year-old underwent surgery on the wrong knee, according to Ms. Jones. A nurse in the post-anesthesia care unit was the first to realize what had happened. Neither the operating room staff nor the surgeon saw the correct mark, and the wrong knee was prepped. Also, nobody checked the patient's records. While a time-out was performed before the procedure, it was cursory and did not help identify the problem.
Here are five tips for preventing wrong-site surgery, according to Ms. Jones:
• Remember that verification should start much earlier than when the patient walks through the door of the ASC — it starts at registration or even at the pre-admission phone call.
• Have consistent time-outs and think about how is it documented and how everyone participates in it to avoid it becoming routine and cursory.
• When reporting the event, write out only the facts that are in the medical record.
• Perform a root cause analysis — a lot of people have to have done something wrong for wrong-site surgery to occur.
• After performing the analysis put processes in place to avoid the mistakes from happening again.
