Nursing

Wrong-site surgery: Your guide to the JCAHO's Universal Protocol

Staff Development Weekly: Insight on Evidence-Based Practice in Education, June 17, 2004

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Question: Mrs. Jones arrives for surgery and requests the bed next to the window of a semi-private room. A few hours after admission, Mrs. Jones trades beds with her roommate. When the transporter arrives to take Mrs. Jones to surgery, he uses bed location as a patient identifier and brings Mrs. Jones' roommate, instead of Mrs. Jones, to the preoperative area for surgery.

Is there any way the surgical team could avoid operating on the wrong person in this case?

Answer: The protocol requires that members of the surgical team use two patient identifiers to verify that they are about to operate on the correct person (verification should also take place before the patient leaves the preoperative area.)

Note: The JCAHO allows the preoperative nurse to serve as a member of the surgical team and mark the site if the surgeon is unable. However, the preoperative nurse is not present when the team performs the time out in the operating room. (Some states prohibit nurses from marking the surgical site, so it's important to check your own state laws.)
If the surgical team follows the protocol, the patient will reveal that she is not in fact Mrs. Jones, and the team will stop plans to conduct the surgery until the correct patient is transported to the area and prepped.

Editor's note: The above case is from the new online course, "Wrong-site surgery: Your guide to the JCAHO's Universal Protocol." For more information on this and other courses in our Mandatory Training library, go to www.hcprofessor.com and click on Annual Regulatory Staff Training.



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