The Surgery Director’s Choice: Wrong side surgery

I get paged a lot every day in my job as director of surgical services. One call I'll never forget came several years ago. There had been a serious mistake: A surgical team had operated on the patient's wrong side.

The patient was in the recovery room, just waking up. The surgeon and I had to deliver the devastating news. I cannot begin to describe our disbelief and shock, shared by everyone involved. The patient, naturally and justifiably, was very angry.

Our team's sense of guilt and grief over this extremely rare event was overwhelming. The surgeon was a good one, the team supporting him, highly accomplished. But there was no escaping the consequences. New in my job, I prepared to resign. I went to my boss and told her that despite all my years as a surgical nurse, I hadn't truly recognized the extent of responsibility in this job. This case had shattered my confidence.

Fortunately, she sat me down for a long talk about the case. I had a choice: either quit, or use this terrible experience to make a difference.

In part because I had told the patient I would do everything I could to make sure this never happened again, I decided to stay. I also started researching data on preventing serious medical errors. We joined in a collaborative effort: Safest in America, which has both significantly changed the delivery of care in Minnesota, and the statewide reporting of errors. The surgeon marks the site, and three additional people sign off on the location BEFORE you arrive in the operating room. Once there, a final check, or "time-out," takes place before the procedure begins.

This protocol is but one small example. But I think that my colleagues and I are making good on the promise I made to that unfortunate patient years ago: We are doing all we can to make sure it doesn't happen again.

Advice to patients: Write “correct” and “wrong side” on your parts before surgery. Only write “correct” on the parts you want to keep.

Read Dana Langness’ full story, or learn more about the Safest in America collaboration.