Wrong-site surgery prevention

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Wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors are rare but fully preventable by the implementation of a safety culture ¹⁾

To prevent wrong-site surgery, the following measures can be taken:

Preoperative verification: Before the surgery, the surgical team should verify the correct patient, correct site, correct procedure, and correct side. This should involve a team discussion, review of medical records, and marking the site of the surgery.

Site marking: The surgical team should mark the site of the surgery with a permanent marker, preferably by the surgeon who will be performing the procedure. This should be done in the presence of the patient or their legal guardian, and the marking should be visible after the patient is prepared for surgery.

Time-out: Before starting the surgery, the surgical team should conduct a time-out, during which they should verify the patient's identity, surgical site, and procedure. This should be a formal pause in the process that involves all team members.

Communication: Effective communication among team members is crucial for preventing wrong-site surgery. The team should ensure that everyone involved in the surgery has a clear understanding of the patient's medical history, the planned procedure, and any potential risks.

Training and education: Healthcare professionals should receive ongoing training and education on preventing wrong-site surgery. This should include learning from past incidents, reviewing best practices, and implementing new procedures and policies to reduce the risk of error.

Reporting and analysis: All incidents of wrong-site surgery should be reported and analyzed to identify the root cause of the error and prevent future occurrences. The surgical team should also review near misses, which are situations where an error almost occurred, to identify areas for improvement.

The risk of wrong-site surgeries is increased with spine surgery, likely due to unique technical challenges. Further research is required to identify effective methods of prevention of these events ²⁾