How Common are Wrong-Site Surgeries?
People each week in U.S. have the wrong surgery performed on them
%
Orthopedic surgeons will commit a wrong-site surgery during their career
%
Neurosurgeons will operate at the wrong site at least once in their career
%
Hand surgeons have admitted to performing the wrong surgery
How Common are Wrong-Site Surgeries?
People each week in U.S. have the wrong surgery performed on them
Orthopedic surgeons will commit a wrong-site surgery during their career
Neurosurgeons will operate at the wrong site at least once in their career
Hand surgeons have admitted to performing the wrong surgery
How Common are Wrong-Site Surgeries?
People each week in U.S. have the wrong surgery performed on them
%
Orthopedic surgeons will commit a wrong-site surgery during their career
%
Neurosurgeons will operate at the wrong site at least once in their career
%
Hand surgeons have admitted to performing the wrong surgery
How Does It Happen?
Even the best surgeons make mistakes
People often assume that wrong-site surgeries happen only to bad surgeons at bad hospitals. The data shows this is not true. Top-rated surgeons working at top-rated hospitals make these mistakes too. Why? Because of a systems error.
How Does It Happen?
Even the best surgeons make mistakes
People often assume wrong-site surgeries happen only to bad surgeons at bad hospitals. The data shows this is not true. Top-rated surgeons working at top-rated hospitals make these mistakes too. Why? Because of a systems error.
Speed and Fatique
Speed and Fatique
Why are there so many wrong-site surgeries? There is constant pressure in operating rooms to move faster and reduce turnover times. Now add fatigue, staffing shortages, and increased demands for services. There’s a solution — keep reading.
Fatigue and Production pressures
Add intense production pressures to marking variability and the risk for human error greatly increases. Operating room clinicians are pushed every day to maximize efficiency.
When emergency cases are “bumped” ahead of scheduled surgeries, surgeons are pushed to work faster to get back to their offices to see patients.
Safety is often sacrificed for speed.
Specialized rooms
As surgeries have become more specialized, the instrumentation, X-ray imaging, patient positioning, and even operating rooms themselves have become tailored for specific types of surgeries. Many rooms are uniquely “sided,” which can lead to wrong-sided surgical errors.
Why are there so many wrong-site surgeries? There is constant pressure in operating rooms to move faster and reduce turnover times. Now add fatigue, staffing shortages, and increased demands for services. There’s a solution — keep reading.
Left–Right or Prone–Supine?
A recent study found that 14.9% of people had difficulty distinguishing left from right. “To operate on the back of someone’s leg, the surgeon may turn the patient from supine to prone, and so left becomes right.” It is especially easy to get confused about this at 2:00 a.m.
Marking Varibility
In busy operating rooms, variation and is the last thing people want. This is when most errors occur. Standardization is the gold standard everyone seeks to achieve.
Lack of Standardized Marks
A lack of standardized surgical marks a large role in many wrong-site surgeries. Marking variability ranges from no mark on the patient to Yes, No, a flower, a smiley face, a straight line, an X to mark the spot, or even an X to warn people not to operate here.
Ideally, all surgical marks will be made in or near the surgical field. However, some surgeons mark only on the patient’s left or right hand to indicate the side of surgery. The problem is that these marks are then hidden by the surgical drapes in the OR.
Surgical Marks Hidden by Drapes
One of the most common factors that cause a wrong-site surgery comes from incorrect pre-operative surgical markings. A surgeon may mark only the patient’s hand to indicate side of procedure. In the OR these marks are often hidden by surgical drapes, which means the surgical team confirms the operative site based solely on memory.
Marking the Wrong Site
Occasionally in the fast-paced operating room environment surgeons will inadvertently mark the wrong site or side. Patients are understandably nervous before surgery and can easily be distracted by all of the activity. They don’t always pay attention to the surgeon’s marks.
Difficulty Seeing the Surgical Mark
One of the most common factors is when surgical site marks are too faint to see, and therefore they don’t function as intended. In cases like this, it is all too easy to operate at the wrong site.
There’s a Solution
Surgi-Sign was invented by an anesthesiologist using Six Sigma process improvement analysis.
Standardized Surgical Marks
Determining where the patient is marked is often a big challenge for circulating nurses. Asking the patient if the surgeon marked you isn’t enough.
The Surgi-Sign gives you a consistent, visual expectation by standardizing all surgical marks.
Active Patient Involvement
Surgi-Sign involves the patient in a very active way: adding a checkmark to their own correct surgical site.
Visible Marks in the Surgical Field
In pre-OP, the Surgi-Sign focuses the surgeon, patient, nurse, and anesthesiologist to crosscheck and confirm the surgical site. If correct, each person adds a mark. In the OR, the tattoo material wipes away in 20 seconds, yet all the marks remain visible and the site is ready for prepping.
There’s a Solution
Surgi-Sign was invented by an anesthesiologist using Six Sigma process improvement analysis.
Standardized Surgical Marks
Determining where the patient is marked is often a big challenge for circulating nurses. Asking the patient if the surgeon marked you isn’t enough.
The Surgi-Sign gives you a consistent, visual expectation by standardizing all surgical marks.
Active Patient Involvement
Surgi-Sign involves the patient in a very active way: adding a checkmark to their own correct surgical site.
Visible Marks in the Surgical Field
In pre-OP, the Surgi-Sign focuses the surgeon, patient, nurse, and anesthesiologist to crosscheck and confirm the surgical site. If correct, each person adds a mark. In the OR, the tattoo material wipes away in 20 seconds, yet all the marks remain visible and the site is ready for prepping.
See HOW IT WORKS
