Preventing Surgical Errors Always a Concern

When you have surgery, you want to trust that simple mistakes won't happen. Though it is rare, sometimes they do.

The Joint Commission, a national organization that works to improve health care safety, receives eight to ten reports a month of people who mistakenly had the wrong site operated on. In addition, the New England Journal of Medicine reports as many as 1500 people a year have a foreign object, like a surgical sponge, left inside.

No one worries more about surgical errors than hospitals themselves. Stormont-Vail's Surgical Services Director Robert Wehmeyer, RN/BSN says even one error is enough of a tragedy that procedures should be in place to make sure it doesn't happen. That's why he says Stormont follows the Joint Commission's protocol.

For starters, you might be asked the same questions a lot. Wehmeyer says to ensure "the right patient, the right procedure and the right site," those items are identified with every hand off to every department.

The final check comes right before the procedure, when they call a time out. Stormont Clinical Educator Caroline Shubert, RN/BSN/CNOR, says the entire team stops right before the incision is made to verify that it's the correct patient, the correct procedure and the correct surgery site, especially in areas where there's a left and right, like an arm or leg. Anyone on the team can raise questions and, if they do, records are re-checked.

Shubert says perioperative nurses play a crucial role in the process. They care for patients before, during and after surgery. Among their duties during surgery, they make sure the patient is positioned properly. Shubert says here's a lot of equipment in the operating room, so the nurse is essential to protecting the patient in this kind of environment.

Another challenge in the OR is making sure all the tools on the tables are back outside the patient when surgery is over. To ensure that, Wehmeyer says a total count of instrumentation is done with every cavity entry and exit and identified on a count sheet.

All agree communication is key to preventing errors, both among hospital staff and with patients. If something doesn't sound right, they say the patients should feel free to speak up and ask questions.

As for other problem errors, Wehmeyer says they don't label medications with abbreviations that could be confused. There's also an effort to better educate patients on preventing post-surgical infections.


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