Submitted to Orsafe.org by Debbie Conn  R.N.,HCRM(contact information below). Ms. Conn is an expert in  RISK MANAGEMENT  and available for reviews, questions and   may be contacted by phone, email and or thewebsite Universal Healthcare listed below. She and her group are indeed avaluable resource and only a phone call away.

 A true measure in OR safety  is the long-term outcome of results achieved  and law suits involving the entire surgicalteam, on top of the patient outcome.

 With all the regulations and requirements for a surgicaltime out, why are we still seeing wrong site surgeries? A question, really aconcern that continues to baffle me. A time-out, which The Joint Commission defines as “animmediate pause by the entire surgical team to confirm the correct patient,procedure, and site,” was introduced in 2003, when The Joint Commission’s Boardof Commissioners approved the original Universal Protocol for Preventing WrongSite, Wrong Procedure, and Wrong Person Surgery for all accredited hospitals,ambulatory care centers, and office-based surgery facilities.(1) This standardspread throughout all state, federal and accrediting body agencies as arequirement for all invasive procedures including surgical, procedural such asGI, ENT, GYN as well as interventional with pain, radiology, cardiology andanesthesia performing blocks. 


In June of 2008: the WorldHealth Organization introduced the surgical safety checklist, which, along withthe “time out” has become a requirement by State, Federal and Accrediting Agencies.This has shown to decrease the number of wrong site surgeries further, yet wehave not eliminated them.


What the surgical safety checklist added that the “time out” process is missing is the confirmation that thesurgical site was marked; however, neither form include in the confirmation theinformed consent. If an informed consent is properly obtained with all theabove information, including the signature of the operating physician, thesignature of the patient and the signature of a witness, it should be includedin the “time out” process. 


So, the question remains- ifall the confirmations are properly completed in following the processes of boththe “time out” and the surgical safety checklist, if the procedure on theinformed consent is different, do you not still have a wrong site surgery?


Adding the steps of obtaininga complete and accurate informed consent and using it throughout the process ofpatient identification in pre-op to both the surgical safety checklist and the“time out” peri-operatively, may actually further decrease the opportunity fora wrong site procedure. Together we can continue down the road of patientsafety and work to eliminate adverse events such as this.


1.      The Joint Commissionon Accreditation of Healthcare Organizations. ComprehensiveAccreditation Manual for Hospitals. Glossary. Oakbrook Terrace, IL. 2017update. (Manual and corresponding updates are subscription-based.)




Debbi Conn, RN, HCRM

Universal Healthcare Consulting 
Office:  561-999-9371
Efax: 561-828-0742
Email: debbi@universalhc.com


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