Rx for Wrong-Site Surgery: Two Minutes of Conversation

A study of Johns Hopkins surgeons, anesthesiologists and nurses suggests that hospital policies requiring a brief pre-operation team meeting to make sure surgery is performed on the right patient and the right part of the body could decrease errors.

In the study, which will appear in the February issue of the Journal of the American College of Surgeons, Hopkins OR personnel were very positive about the briefings, according to surgeon Martin Makary, MD, MPH, director of the Johns Hopkins Center for Surgical Outcomes Research and lead author of the study.

Although we lack systems for uniform reporting of wrong-site surgeries to understand the extent of the problem, we observed team meetings increase the awareness of OR personnel with regard to the site and procedure and their perceptions of operating rooms safety says Makary. He stressed that wrong-site surgery is exceptionally rare but entirely preventable.

A study published last year in the Archives of Surgery that looked at 2.8 million operations in Massachusetts over a 20-year period suggests that the rate of wrong-site surgery anywhere other than the spine is 1 in every 112,994 operations. The study excluded the spine because researchers defined wrong-site surgeries as operations conducted on a different organ or body part than intended by the surgeon and patient. Since the spine is one body part, even though a surgeon may have operated on the wrong part of the spine, technically it is still the right part of the body.

The Joint Commission, which evaluates and accredits nearly 15,000 healthcare organizations and programs in the United States, requires hospitals to have a pre-surgical conversation in the OR before every surgery.

Although Makary says no national standard was set by the Joint Commission, he and others led efforts at Hopkins to enforce the mandate, developing a standardized OR briefing program that became Hopkins Hospital policy in June 2006. Since then, he has collaborated with Rochester University, Yale, Columbia and Cornell and the World Health Organization to broaden the use and reach of the Hopkins program.

The briefing consists of a two-minute meeting during which all members of the OR team state their name and role, and the lead surgeon identifies and verifies such critical components of the operation as the patients identity, the surgical site and other patient safety concerns. The briefing is performed after anesthesia is administered and prior to incision.

A survey, among 147 surgeons, 59 anesthesiologists, 187 nurses and 29 other OR staff, was given twice -- before implementing the policy and after it had been in effect for three-months.

After training, a 13.2 percent increase in those who believed the policy would be effective was recorded among the OR personnel. And more than 90 percent agreed that a team discussion before a surgical procedure is important for patient safety.

The Joint Commission identified communication breakdowns as the most common root cause of wrong-site surgeries, says Makary. Our research indicates that OR personnel see pre-surgical briefings as a useful tool to help prevent such errors.

Before the new policy was implemented, Makary notes, many surgeons would walk into the OR and start working without a conversation of any kind and without even knowing the names of the nurses and other staff who were assisting them.

The survey is based on a similar questionnaire designed by the airline industry to assess programs designed to reduce safety errors.

Hopkins faculty members Peter J. Pronovost, MD, PhD, and Bryan Sexton, PhD, also contributed to the article.

Source: Johns Hopkins