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Avoiding Wrong Site Surgery

Jun 21 2011

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20/20 Blog

Although I have never operated on the wrong eye, I have witnessed three near misses. A review of nearly 1000 surgical cases at five different hospital operating rooms revealed a common pattern that lead to the wrong eye being set for surgery.

In each case, the Joint Commission Universal Protocol was followed with the patient appropriately marked and a time out verification with all OR staff. While I was scrubbing, the operating room nurse placed the drape over the wrong eye. In each of the three cases, I realized something was incorrect prior to the first incision. Two cases were noticed as the nurse was placing the drape. One case was noticed after the microscope was engaged, and the entire prep and drape had to be performed again. Fortunately, in no case was an incision made.

After reviewing these cases, I realized the main problem was that tape used to secure the patient’s forehead was covering the marked site, and the color of the povidine-iodine on the skin was difficult to identify once it dried, especially on darkly pigmented patients. The problem may have been compounded since patients were under anesthesia when being draped.

In order to eliminate the possibility of operating on the wrong eye, I have added an additional step to the recommended “time out” procedure. Just before the block is given, a metal shield is taped over the non-surgical eye. This is verified with the patient before anesthesia is started. The retrobulbar injection is then given and the patient is prepped. When the nurse comes to drape the patient, regardless of tape, skin color, anesthesia, or my presence, it is absolutely clear which eye is to be operated upon. The contralateral eye is also protected from accidental trauma during the procedure.

The fellow-eye shield  step is now part of my resident and fellow training. This protocol keeps the responsibility squarely in the hands of the surgeon and will reduce this type of wrong site surgery error.