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Thursday, September 24, 2009

Write on the incision site: Wrong site wrist/finger surgery

Here is an example of what has been reported and the initial changes made as a result of Massachusetts hospitals' analyses of "serious reportable events," as required in the new Chapter 305 state law.

A Spanish speaking only patient was admitted for surgery to release a left trigger finger, a condition where the finger catches in a bent position and straightens with a snap; instead she had a carpal tunnel release, a completely different operation on the wrist and not the finger.
This mistake was not discovered by the team in the operating room, but by the doctor when he returned to his office and looked at the patient's medical record.

To avoid this error from recurring, the hospital changed its policy from having the surgeon sign the side of operation to requiring the surgeon to sign the actual incision site. Also in this case, not all team members participated in the time out. In response, two more important issues were addressed by the facility: first, the policy was changed to require the presence of an interpreter for non-English speaking patients, so they could answer questions about the operation and verify the site, as required by the Universal protocol; and second, a revised hand-off routine was instituted to accommodate changes in staff immediately before and during the operation.

Advice to surgical patients: Have the surgeon mark the incision site, not just the correct side of your body – or mark it yourself.

Kudos to Dr. Stancil Riley, Tracy Gay of the Betsy Lehman Center, and Elizabeth Daake of DPH to helping this happen and making this available at the Massachusetts Department of Public Health's website.

Read another wrong-site surgery story.

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