Association of periOperative Registered Nurses (AORN) Position Statement on Correct Site Surgery
Preamble
The Institute of Medicine’s (IOM) report To Err is Human: Building a Safer Health System has brought national attention to the necessity to improve patient safety.1 A comprehensive approach is needed in each health care delivery system to prevent wrong-site surgery. Procedures and protocols should be developed collaboratively by multidisciplinary teams, including surgeons, perioperative RNs, anesthesia care providers, risk managers, and other health care professionals. Perioperative RNs should be key participants in multidisciplinary teams as they develop these procedures and protocols. As patient advocates, perioperative RNs have a duty to the public to protect the patient from injury and to safeguard the patient’s health, welfare, and safety.2 A central goal of perioperative nursing is to assist patients in achieving a level of wellness equal to or greater than that which they had before surgical intervention. While it is the surgeon’s responsibility to diagnose the patient’s need for surgery and to delineate the surgical site, verifying the correct surgical site at the time of surgery is the responsibility of each health care provider, including perioperative RNs.
Background
Wrong-site surgery is a broad term that encompasses all surgical procedures performed on the wrong patient, wrong body part, wrong side of the body, or at the wrong level of the correctly identified anatomic site.3 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) considers all wrong-site surgeries, regardless of the extent of the procedure, to be sentinel events. As such, they are reviewable under the JCAHO sentinel event procedure.4 This procedure calls for a root-cause analysis of each sentinel event. Review of several root-cause analyses by the JCAHO Accreditation Committee of the Board of Commissioners found wrong-site surgery most commonly occurs during orthopedic procedures, followed by urological and neurosurgical procedures.5
Recognizing that wrong-site surgery is most common in orthopedic procedures, the American Academy of Orthopaedic Surgeons (AAOS) is committed to eliminating the incidence of wrong-site surgery. The AAOS has developed a Wrong-Site Surgery Advisory Statement in which it notes that it is the surgeon’s responsibility to identify and mark the correct surgical site.6 Recognizing that wrong-site surgery is not only an orthopedic problem, the AAOS has called for a comprehensive effort by other surgical specialties and health care professionals in developing protocols to effectively eliminate wrong-site surgery.
Contributing factors
Performing surgery on the wrong site can have serious consequences for the patient. Patients may be affected emotionally as well as physically from surgery performed on the wrong surgical site. An ineffective surgical site verification procedure can contribute to the incidence of wrong-site surgery. Procedure shortcomings might include:
- inadequate patient assessment;
- inadequate medical record review;
- lack of institutional controls;
- miscommunication among members of the surgical team and the patient;
- exclusion of certain surgical team members;
- reliance solely on the surgeon for determining the correct surgical site.7
Other factors that might contribute to an increased risk of wrong-site surgery include:
- having more than one surgeon involved in the procedure;
- performing multiple procedures on multiple parts of a patient during a single surgical encounter;
- unusual time pressures;
- pressure to reduce preoperative preparation time;
- patient characteristics requiring unusual equipment setup or patient positioning;
- failure to include the patient and/or family members/significant others when identifying the correct site;
- incomplete or inaccurate communication among members of the surgical team.8
Risk-reduction strategies
AORN is in agreement with and suggests the following strategies for developing facility procedures/protocols for identifying the correct surgical site:9
- Involve the patient and/or family members/significant others in identifying the correct site.
- Use a specified, clear, unambiguous, indelible method for marking only the correct surgical site.
- Specify in individual facility policy and procedure how, when, and by whom the surgical site is to be marked.
- Use a verification checklist immediately before surgery that includes the following:
- verbal communication with the patient and/or family members/significant others;
- medical record review, including the face sheet, history and physical, and preoperative assessment;
- review of the informed consent;
- review of all available imaging studies;
- direct observation of the marked surgical site.
- Verbally verify the correct site with each member of the surgical team.
- Use quality control initiatives to monitor compliance with protocol.
AORN’s position
AORN is committed to promoting identification of the correct surgical site. Using the suggested risk-prevention strategies when developing policies and procedures will reduce the risk of error. As patient advocates, perioperative RNs should communicate with all members of the surgical team to verify the correct surgical site. Individual facility policy should clearly delineate the role and responsibility of the physician and other team members in marking and verifying the correct surgical site.
Definitions
Sentinel event. "A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase or the risk thereof’ includes any process variation for which a recurrence would carry a significant chance of serious adverse outcome. Such events are called sentinel’ because they signal the need for immediate investigation and response."10
Wrong level/part surgery. A surgical procedure that is performed at the correct site, but at the wrong level or part of the operative field. For example, performing a lumbar laminectomy on an unintended intervertebral level immediately adjacent to an intervertebral level with identified pathology. In this type of error, the correct part of the body is prepped and draped, but the surgical procedure is performed on the wrong level of the patient’s anatomy.11
Wrong patient surgery. A misidentification of the patient. This type of error includes procedures that are performed on the wrong patient.12
Wrong side surgery. A surgical procedure that involves errors on extremities or distinct sides of the body.13
Wrong-site surgery. A broad term that encompasses all surgical procedures performed on the wrong body part or the wrong patient.14
References
1. Institute of Medicine. To Err is Human: Building a Safer Health System (Washington, DC: National Academy Press; 2000).
2. "ANA code for nurses with interpretive statements: Explications for perioperative nursing," in Standards, Recommended Practices & Guidelines (Denver: AORN Inc; 2001) 53-70.
3. "Sentinel events," in Comprehensive Accreditation Manual for Hospitals: The Official Handbook (Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; November 2000) SE-2. ECRI, "Operating room risk management," ORRM Surgery 23 (August 2000) 1-2.
4. "Sentinel events," SE-2.
5. Joint Commission on Accreditation of Healthcare Organizations. "Lessons learned: Wrong site surgery," in Sentinel Event Alert, no 6. Available from www.jcaho.org/edu_pub/sealert/sea6.html. Accessed Jan. 3, 2001.
6. American Academy of Orthopaedic Surgeons. American Academy of Orthopaedic Surgeons Advisory Statement, Wrong-Site Surgery. Available from www.aaos.org. Accessed Jan. 3, 2001.
7. Joint Commission on Accreditation of Healthcare Organizations. "Lessons learned: Wrong site surgery." ECRI, "Operating room risk management," 5-6.
8. Ibid.
9. Ibid.
10. "Sentinel events," SE-1.
11. ECRI, "Operating room risk management," 2.
12. Ibid.
13. ECRI, "Operating room risk management," 1.
14. "Sentinel events," SE-2; ECRI, "Operating room risk management" 1.
Original statement adopted by Board of Directors in February 2001. Ratified by the House of Delegates, Dallas, March 2001. Sunset Review: March 2006.
Source: Reprinted with permission, AORN Inc., www.aorn.org and AORN Journal (73 June 2001, in press). Copyright © AORN Inc., 2170 S. Parker Road, Suite 300, Denver, CO 80231.
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