wrong site surgery

1. Battling Wrong Site Surgery
Rhonda L. Anders, MSM, BSN, RN, CNOR, NE-BC
Director, Perioperative Services
Franciscan St. Francis Health Indianapolis, IN
November 18, 2013

2. Rhonda Anders, MSM,BSN,RN,CNOR,NEBC
RHONDA ANDERS HAS BEEN A PERIOPERATIVE REGISTERED NURSE FOR 23 YEARS AND
HAS FULFILLED THE FOLLOWING ROLES: STAFF NURSE, CLINICAL EDUCATOR, CLINICAL
MANAGER, AND PERIOPERATIVE SERVICES DIRECTOR. AS SHE PROGRESSED THROUGH
THE VARIOUS STAGES OF HER CAREER, SHE RELIED MORE HEAVILY ON EVIDENCE-BASED
PRACTICE AND ENGAGEMENT WITH AORN. SHE SERVED AORN ON THE NATIONAL BOARD
OF DIRECTORS FROM MARCH 2007 – MARCH 2011. SHE HAS PREPARED AND PRESENTED
DOZENS OF EVIDENCE-BASED PRESENTATIONS RELATED TO SAFETY IN THE PERIOPERATIVE
SETTING.

3. Disclosure Information
AORN’s policy is that the subject matter experts for this product must disclose any financial relationship in a company
providing grant funds and/or a company whose product(s) may be discussed or used during the educational
activity. Financial disclosure will include the name of the company and/or product and the type of financial relationship,
and includes relationships that are in place at the time of the activity or were in place in the 12 months preceding the
activity. Disclosures for this activity are indicated according to the following numeric categories:
1. Consultant/Speaker’s Bureau:
2. Employee
3. Stockholder
4. Product Designer
5. Grant/Research Support :
6. Other relationship (specify) :
7. Has no financial interest: None
Speaker:
Rhonda Anders, MSM,BSN,RN,CNOR,NEBC
Discloses no conflict
Accreditation Statement
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019.
AORN IS PLEASED TO PROVIDE THIS WEBINAR ON THIS IMPORTANT TOPIC. HOWEVER, THE VIEWS
EXPRESSED IN THIS WEBINAR ARE THOSE OF THE PRESENTERS AND DO NOT NECESSARILY REPRESENT THE
VIEWS OF, AND SHOULD NOT BE ATTRIBUTED TO AORN.
Planning Committee:
Ellice Mellinger MS, BSN, RN, CNOR
Discloses no conflict
4

4. Learning Objectives
• Catalogue early attempts at
preventing wrong site surgery
• Analyze the impact of culture on
wrong site surgery
• Compose tactics for the
prevention of wrong site surgery

5. Battling Wrong Site Surgery

6. Introducing Time Outs:
Our Primary Weapon
January 2003 National Patient Safety
Goals
1. To improve the
accuracy of patient
identification by using
two patient identifiers
and a time out
procedure before
invasive procedures
2. To eliminate wrong-site,
wrong-patient, and wrong
procedure surgery using a
preoperative verification process
to confirm documents, and to
implement a process to mark the
surgical site and involve the
patient/family
Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries.
AORN Connections, 5-6

7. The Joint Commission 2004
Universal Protocol for Preventing Wrong Site, Wrong
Procedure, and Wrong Person Surgery
Key Defenses in the Battle:
The Time Out
Preoperative Verification
Process
Marking of the Operative Site
Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries. AORN
Connections, 5-6

8. AORN’s 2004 Contributions
to the Battle
Correct Site Surgery Tool Kit National Time Out Day
Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries. AORN
Connections, 5-6.

9. TJC’s Center for Transforming
Healthcare Adds to Our Arsenal
2009 Wrong Site Surgery Project
Booking Errors
Verification Errors
Errors Caused by
Distracting or
Rushing
Elements of the time out not
verbalized
Inconsistent Site Marking
Lack of a Fully Functioning
Safety Culture
Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries. AORN
Connections, 5-6

10. Targeted Solutions Tool for Wrong
Site Surgery
February 2012 Developed from Findings of
the Wrong Site Surgery Project:
 Guides healthcare providers through a step-by-
step process to assess their vulnerabilities
 Risk begins as the case is booked due to
variations in processes
 Identifies specific risk factors unique to each
organization
 http://www.centerfortransforminghealthcare.org/
DeJohn, P. (2012). Joint Commission tools to prevent wrong surgery. OR Manager, 1-3.

11. All These Weapons Have Reduced
Wrong Site Surgery in the United
States
False

12. US Department of Energy (DOE)
Guiding Principles of Safety
Leadership Commitment is Essential for
Creating a Culture of Safety
• Senior managers demonstrate their
commitment to safety in both word and action
• Patient safety leadership walk rounds
• Safety Attitudes Questionnaire
Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A Defense
Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.

13. Safety Attitudes Questionnaire
Courtesy of Pascal Metrics, Inc. 2013.

14. US Department of Energy
Guiding Principles of Safety
Everyone is Responsible for Safety
• Regardless of position or level within the
organization, everyone must be empowered to
raise safety issues or question an action that
compromises safety
• The ability of staff to raise concerns
influences safety
Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient Safety: A
Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient Safety, 233-240.

15. Safety Attitudes Questionnaire
Courtesy of Pascal Metrics, Inc. 2013.

16. US Department of Energy
Guiding Principles of Safety
Empower Governing Bodies to Create and
Enforce Safety Policies
Defense Nuclear Facilities Safety Board
(1988)
 Congress charged this independent
oversight organization to develop
 meaningful safety standards
 ensure consistent requirements for
management and contractors
 raise technical competence to ensure
protection of workers and the public
 Created industry wide process to review,
identify, and prevent hazards and share
best practices to improve safety
Agency for Healthcare Research and
Quality (AHRQ)
 Called for a single national healthcare
safety body to coordinate standards
and deliver widespread communication
regarding safer health care policies
 Tubing and catheter connection errors:
brought forth the need to standardize
safety approaches with connections
Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient
Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient
Safety, 233-240.

17. US Department of Energy
Safety Standards
Eliminate Preventable Harm
• Injuries are preventable
• DOE sets the safety goal to
ZERO
• Injuries, events, and
accidents are not tolerated
• Learning mentality for
prevention and improvement-
involves critique,
investigation and correction.
Identified In Progress Resolved
Defect, or
near miss
identified by
front line
staff, dated,
and placed
on this
section of the
Learning
Board
Identified issues
placed here
when “who” is
assigned to
address
When the
issue is
resolved, or
problem
solved, it is
placed here
along with a
date of
completion
Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient
Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient
Safety, 233-240.

18. Learning Board in Action
Identified In Progress Resolved
Patient stated, “Total
Hysterectomy” while
consent stated,
“Vaginal Hysterectomy”.
No mention of Salping-
oopherectomy. What is
the meaning of Total
Hysterectomy to a
patient? Is this a wrong
procedure about to
occur?
Assigned to Quality
Manager and OR
Manager to determine
how to incorporate
patients’ verbiage into
consent forms to
assure that what they
believe is about to
occur is congruent with
what the OR team
believes is about to
occur.
Consent re-designed
to prompt additional
dialogue free of
medical jargon. New
consent stresses the
importance of
understanding what
the procedure is in
the patients’ own
words.

19. New Language in Consents
• Authorization For and Consent to Surgical
Operations, Diagnostic and Therapeutic Procedures
• Doctor/or designee should write proposed procedure
here in the patient’s own words
• Please tell me, in your own words, the proposed
procedure you are having:
____________________________________________
____________________________________________

20. Learning Board Fighting Wrong Site
Surgery at All Levels
Identified In Progress Resolved
Case was scheduled
as “left carpel tunnel
decompression”. It
should have been
scheduled as “left
carpel tunnel
decompression, left
cubital tunnel
release”.
Assigned to Surgery
Scheduling
Supervisor. Explore
documentation of
request from Dr. X’s
office, examine
processes to
determine where
defect occurred.

21. Establish a Universal, Uniform
Approach for Safety Management
• Integrate safety into all facets of work planning
and practices.
• Hazards must be understood with preventative
controls in place before engaging in any
activity
• Clear and unambiguous roles and
responsibilities are established for ensuing
safety.
• Use of Checklists
Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for Patient
Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality and Patient
Safety, 233-240.

22. US Department of Energy
Guiding Principles of Safety
Mandate Reporting of Safety Issues,
Errors and Near Misses
• DOE views front line staff as most important
resource for preventing and reporting
hazards and potentially unsafe practices
• An effective reporting culture encourages
and maintains employees’ open expression
of concerns with no fear of retaliation
Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework
for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on
Quality and Patient Safety, 233-240.

23. Mandate Reporting of Safety Issues,
Errors and Near Misses Continued
• Near misses signal system weaknesses, and
because harm did not occur, may provide
insight into solutions
• Although the national Patient Safety Quality
and Improvement Act of 2005 provides
confidentiality for reports of medical errors to
accredited patient safety organizations, only
27 states require hospitals and/or other
medical facilities to report serious medical
errors
Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for
Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality
and Patient Safety, 233-240.

24. Identifying Weakness
• Repeated reports of missing instruments and
instrument set sheet not matching actual
contents
• Repeated reports of missing indicators in sets
• Reports of incorrect packaging for peel packs
TROUBLE IN CENTRAL STERILE PROCESSING
(CSP)!

25. Taking Action Before Harm
• Reviewed hours worked by CSP staff
- No one with less than 90 hours pay for last 3 pay periods.
- One employee at 153 hours / pay
• Implemented instrument tracking system
- required the updating of all set sheets
- gives us the ability to identify where defects occur in the
process
• Added annual mandatory training
- to review sterilization indicators and peel packs that go with the
different methods of sterilization

26. US Department of Energy
Guiding Principles of Safety
Cultivate Learning as Part of the Organizational Mentality
 Open trusting environment
 Focus on injury prevention
 Front line staff freely question processes
 Sense of ownership for improving the workplace
 Mechanisms such as occurrence reporting, incident investigation,
root cause analysis, and self assessments contribute to the
learning process.
 Medical simulation enhancing learning cultures across healthcare
continuum
Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A Framework for
Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The Joint Commission Journal on Quality
and Patient Safety, 233-240.

27. Four Components to the Briefing
Everyone knows the game plan
Psychological safety is ensured
Norms of conduct are discussed
Expectation of excellence is set
Berenholtz, S., Schumacher, K., Hayanga, A., Simon, M., Goeschel, C., Pronovost, P., et al. (2009).
Implementing standardized operating room briefings and debriefings at a large regional medical center. Joint
Commission Journal on Quality and Patient Safety, 391-397.

28. The Briefing
Creating Connection with the Patient
Is it the gallbladder in
room 9….or…
Is it…Our patient Rhonda Anders,
- 46-year old female
- Recent history of tibial plateau fracture
followed by a series of Deep Vein Thrombosis
(DVT)
- Currently taking 6 mg of Coumadin daily with
an INR of 2.6
- She’s showing signs of sepsis so we’ve got to
get her gallbladder out today
- I have no special equipment or instrument
needs
- But does this information raise questions for
any of you?

29. The Briefing
Creating Connection as a Team
Surgeon: “Hey guys.”
Staff: “Good morning Dr.
Mandelbaum.”
Anesthesiologist, “Hey Jon, how
was your trip to Florida last
week?”
New employee scrubbed in but
never introduced…
Or…
Surgeon: “Hey guys.”
RN Circulator: “Good morning Dr.
Mandelbaum. This is Stacy Wilson.
She’s a new nurse with us at St.
Francis, but not new to the OR”
Stacy RN: “I’ve been in the OR for the
past 12 years. Nice to meet you”
Anesthesiologist: “You used to work at
Methodist, didn’t you? I thought I
recognized you”
Dr. Mandelbaum: “If any of our
equipment or supplies look foreign to
you, be sure to ask your preceptor or
me for information”

30. Debriefing is the element that
links
teamwork and improvement
Berenholtz, S., Schumacher, K., Hayanga, A., Simon, M., Goeschel, C., Pronovost, P., et al. (2009).
Implementing standardized operating room briefings and debriefings at a large regional medical
center. Joint Commission Journal on Quality and Patient Safety, 391-397.

31. The Debriefing
Creating a Learning Organization
Surgeon: “Thanks everybody. Go ahead
and get the next patient into the room as
soon as you can. I’m going over to 3
West for a few minutes to round.”
Staff: “Okay, we’ll page you when the
patient is in the room.”
Anesthesiologist: “See you in about 20
minutes, okay…?”
Or…
RN Circulator: “Let’s do the debriefing now. What
went well today?”
Surgeon: “Everything from my perspective, you
guys did a great job, thanks. Stacy, nice job! Was
there anything you would have liked to have been
different?”
Scrub: “The lap chole set had a hole in the wrapper.
Can you write up a defect sheet and request that this
set go into a rigid container.”
RN Circulator: “Will do. Is there anything we should
do differently next time?”
New Staff Member Stacy RN: “Yes, I didn’t know Dr.
Mandelbaum’s special instruments. I felt like I was
fumbling. Can you go over those with me before the
next case.”

32. Communicate Clearly
The Least Expensive Weapon!
Structured Communication
SBAR
Situation
Background
Assessment
Recommendation
Repeat Back
Structured Critical Language

33. Critical Language
A Phrase That Stops the Work
• “I need a little clarity”
• “I am concerned”
• “I am unclear”
• “This is unsafe”

34. Stopping the Work
Surgery Attendant (SA) arrives at entrance doors to room 12 with patient.
The RN Circulator sees the patient and says, “Stop! I have a concern I need to address.”
To SA and Patient, the RN Circulator says: “I’ll be right out to explain.”
• Rooms 12 and 14 were doing Total Joint Jump
Rooms
• Room 14’s patient was about to be brought into
Room 12
• They were both having total hip replacements, but
on different sides. What if…

35. Environment Rife with Embarrassment or
Psychological Safety
Psychological Safety:
A belief that one will not be
humiliated or punished for
speaking up with ideas,
questions, concerns, or
mistakes
A shared sense of
psychological safety is a
critical element in an
effective learning system
Embarrass:
Feel self-conscious or ill at
ease
Have your composure
disturbed
Feel uncomfortable because of
shame or wounded pride
Edmondson, A. (1996). Psychological Safety and Learning Behavior in Work Teams.
Administrative Science Quarterly, 350-383.

36. Do You Have to Protect
Your Image at Work?
• Edmondson, A. (1996). Psychological Safety and Learning Behavior in Work Teams.
Administrative Science Quarterly, 350-383.
• Don’t ask questions
• Don’t ask for feedback
on your performance
• Don’t look doubtful or
criticize
• Don’t suggest anything
innovative
To Protect One’s Image: If you don’t want to look…
STUPID
INCOMPETENT
NEGATIVE
DISRUPTIVE

37. Stupid
Incompetent
Negative
Disruptive
Psychological Safety to Question the
Status Quo
• Ask Questions
• Ask for Feedback
• Be Doubtful
• Be Innovative
Edmondson, A. (1996). Psychological Safety and Learning Behavior in Work Teams.
Administrative Science Quarterly, 350-383.

38. The Fight Continues…
Use ALL Weapons at Your Disposal
Time Out
Preop Verification
Site Marking
Checklists
CSS Tool Kit
National Time Out Day
Targeted Solutions
Tool
Briefing
Skilled
Communication
Debriefing
Learning Culture
Psychological Safety

39. References
Berenholtz, S., Schumacher, K., Hayanga, A., Simon, M., Goeschel, C., Pronovost, P., et al. (2009).
Implementing standardized operating room briefings and debriefings at a large regional medical
center. Joint Commission Journal on Quality and Patient Safety, 391-397.
Birnbach, D. J., Rosen, L. F., Williams, L., Fitzpatrick, M., Lubarsky, D., & Menna , J. D. (2013). A
Framework for Patient Safety: A Defense Nuclear Industry-Based High-Reliability Model. The
Joint Commission Journal on Quality and Patient Safety, 233-240.
DeJohn, P. (2012). Joint Commission tools to prevent wrong surgery. OR Manager, 1-3.
Edmondson, A. (1996). Psychological Safety and Learning Behavior in Work Teams. Administrative
Science Quarterly, 350-383.
Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries. AORN
Connections, 5-6.
Pascal Metrics, Inc. 2013

40. Thank You for Your Time