You know that patient safety is not a priority in a hospital when your state regulatory agency orders that cameras be installed in your operating rooms.
Rhode Island Hospital has had five wrong-site surgeries since 2007. Here is how the AP described the last incident:
The latest incident last month involved a patient who was to have surgery on two fingers. Instead, the surgeon performed both operations on the same finger. Under protocols adopted in the medical field, the surgery site should have been marked and the surgical team should have taken a timeout before cutting to ensure they were operating on the right patient, the right part of the patient’s body and doing the correct procedure.
The hospital was also fined $150,000.
Each of these incidents are completely unacceptable.
Here is the recommendations of the American College of Surgery on how these incidents can be prevented:
- Verify that the correct patient is being taken to the operating room. This verification can be made with the patient or the patient’s designated representative if the patient is under age or unable to answer for him/herself.
- Verify that the correct procedure is on the operating room schedule.
- Verify with the patient or the patient’s designated representative the procedure that is expected to be performed, as well as the location of the operation.
- Confirm the consent form with the patient or the patient’s designated representative.
- In the case of a bilateral organ, limb, or anatomic site (for example, hernia), the surgeon and patient should agree and the operating surgeon should mark the site prior to giving the patient narcotics, sedation, or anesthesia.
- If the patient is scheduled for multiple procedures that will be performed by multiple surgeons, all the items on the checklist must be verified for each procedure that is planned to be performed.
- Conduct a final verification process with members of the surgical team to confirm the correct patient, procedure, and surgical site.
- Ensure that all relevant records and imaging studies are in the operating room.
- If any verification process fails to identify the correct site, all activities should be halted until verification is accurate.
- In the event of a life- or limb-threatening situation, not all of these steps may be followed.
I have written about this subject several times, most recently here. Here are the "best practices" on this subject as developed by the Tennessee Improving Patient Safety program>