- done on the wrong patient--8%
- the wrong procedure--9%
- the wrong side of the body (ie, as above, or left knee rather than right knee)--70%
- or the wrong part of an anatomic structure (ie wrong spinal level in back surgery, wrong finger in the correct hand) --14%
- The surgeon should be fully engaged in the formal time-out. He/she should consider a full preoperative briefing.
- The surgeon should be explicit about the procedure and its indication(s), including the side or site as appropriate. This should be included in the patient's records (ie H&P).
- The consent should be obtained from the patient by the surgeon, explicitly stating the procedure including the side or site as appropriate.
- There should be a reliable system for accurately transmitting information from the surgeon's office to the OR nurse.
- Have an initial-time out in the OR before caring for a patient undergoing elective surgery.
- The marking of the operative site should be reconciled by the surgeon and patient together.
- The surgeon should discuss new findings and changes in plans with other members of the operating team.
- Labeling the specimen--reconciliation should include the surgeon, the operating technician, and the circulating nurse. There should be a chain of custody for irreplaceable specimens.
- Multiple and ancillary procedures should be included in the formal timeout.
- Repeat formal time-out processes for independent procedures.
Getting Surgery Right, Preventing Wrong-site Site Surgery--MedScape Article
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery ™ -- the Joint Commission
Wrong-site Surgery-- Agency for Healthcare Research and Quality