Oops in the Operating Room: Wrong Site Surgery and Prevention With Asset Tracking

We’ve all heard at some point or another, a story about an accident in a hospital operating room. Or a patient who underwent the wrong procedure. Or even a patient who underwent the correct procedure but on the healthy body part. The event of "wrong site surgery" is becoming more known. These are harrowing situations for all parties involved and unfortunately, one mistake can create a lifetime of trouble for the patient and the caregiver. From the removal of perfectly healthy organs to unnecessary risk and injury to wasted resources, accuracy in hospitals is critical. It’s essential that hospitals and staff deliver the right care to the right patient at the time. In order to do that, the right resources need to be identified and kept in optimal working condition.

 Wrong Site Surgery: How Often Does It Happen?

The thought of asset tracking and allocation probably isn’t first of mind as a patient when you are about to undergo a procedure. But in all actuality, it should be very important to you. You want to be 100% sure that the medical team who is about to care for you have every tool and piece of equipment needed and that it’s fully functional. You also want to know that they are completely in the know about your specific procedure and ready to give their focus to and on you before, during and after the procedure.

It’s scary to think that your safety and your life are in the hands of others and you are not able to have any control once you are under. The “what if’s” and “what could happen” thoughts are common. Unfortunately, the stories of mistakes and errors that cause harm do get reported in the media and can cause anxiety in any patient.

While rare, Wrong Site Surgery (WSS) also known as never events, are errors that should never occur and indicate serious underlying safety problems. The term "Never Event" was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. The NQF initially defined 27 such events in 2002. The list has been revised since then, most recently in 2011, and now consists of 29 events grouped into 7 categories: surgical, product or device, patient protection, care management, environmental, radiologic, and criminal.

study estimated that such errors occur in approximately 1 of 112,000 surgical procedures, infrequent enough that an individual hospital would only experience one such error every 5–10 years. So they aren’t very common, but ideally they shouldn’t have to happen at all.

Wrong Patient Errors: Why They Matter and How to Prevent Them

While the incidence of reported WSS has increased in recent years, there are steps and procedures in place to get them under control and keep that number from going up. The Joint Commission on Accreditation of Healthcare Organizations, now referred to as the Joint Commission, found WSS’s to be the third highest-ranking event on its list of “sentinel events”, which are defined as an unexpected occurrence involving death or serious physical or psychological injuries, or the risk thereof. The Joint Commission issued two National Patient Safety Goals on January 1, 2003, to target wrong-site surgery:
  1. to improve the accuracy of patient identification by using two patient identifiers and a “time-out” procedure before invasive procedures.
  2. to eliminate wrong-site, wrong-patient, and wrong-procedure surgery using a preoperative verification process to confirm documents, and to implement a process to mark the surgical site and involve the patient/family.

Regardless of the technology or approach of the procedure, careful planning for the individual patient is the first step in any medical intervention that will keep the team on track and hopefully with significantly fewer errors.

Getting the Right Treatment for the Right Patient

 It used to be that surgical procedures were traditionally performed in acute care settings. However today, that is not the case. Many procedures are now being performed in freestanding surgical centers and physician offices. Surgeons, surgical teams, and patients need to be vigilant with all surgeries, particularly when the level of oversight and scrutiny may not be as high as in hospitals and that includes being aware of all assets that will or may need to be used.

From medication and dosage to the correct handling of blood, organs and other biological resources, its imperative that all parties know what assets are needed for each procedure and that they are for the correct patient.

Patient identification should always be established from the moment they enter the facility. There are lots of items (ie assets) being used and transferred from place to place such as medication, vials of blood or other bodily fluids. Having set procedures in place to correctly identify these assets and who they belong to are key. Scanning any of these items into an asset tracking database as they go from place to place helps healthcare workers know where they are and who has them at any given time.

The World Health Organization (WHO) has suggested strategies that can help eliminate WSS errors by starting with patient identification practices, which will also give patients peace of mind that their caregivers know who they are/any special needs and are addressing them:

Here are a few key ones:
  1. Emphasize the primary responsibility of health-care workers to check the identity of patients and match the correct patients with the correct care (e.g. laboratory results, specimens, procedures) before that care is administered.
  2. Encourage the use of at least two identifiers (e.g. name and date of birth) to verify a patient’s identity upon admission or transfer to another hospital or other care setting and prior to the administration of care.
  3. Encourage the labeling of containers used for blood and other specimens in the presence of the patient.
  4. Provide clear protocols for questioning laboratory results or other test findings when they are not consistent with the patient’s clinical history.
IoT and Healthcare

Just as in business, healthcare is also moving toward an Internet of Things (IoT) -- a world in which all devices are tagged with unique barcodes and can “speak.” This coding enables more efficient healthcare asset management and an overall reduction in potential life-threatening errors.

Keeping equipment in optimal working condition is so important. Lives literally can depend on a machine and its ability to do its job. Consider the following scenario -- A piece of medical equipment could send a message signaling that it’s time for maintenance to be performed and it is logged into an asset tracking and management database, which in turn gives an alert to the team that it needs servicing. That communication allows the hospital to stay on top of timely service schedules and avoid a breakdown, expensive repairs and even premature replacement. This is the future. But for now, working in conjunction with healthcare asset management software, the simple act of scanning and tracking barcodes enables hospitals and clinics to monitor the condition of and keep track of vital equipment.

Asset Panda has invested years of research, development, and testing to create the world’s most powerful asset tracking platform. Clients, including major healthcare organizations, use our free mobile iOS and Android apps to help them better manage their vital assets and equipment. With Asset Panda, there’s no limit on the number of users, so you can get everyone on board for better results. The platform is both flexible and completely customizable, enabling the entire medical team to track assets any way needed and make changes at any time. Designed with the Internet of Things in mind, it’s flexible enough to incorporate new technologies as they become available in the future. There is no additional hardware needed to use Asset Panda – not even a separate handheld barcode scanner, as the app also includes a mobile scanner. And, because Asset Panda syncs with the cloud, the information you depend on to provide the best patient care is always available in real time.

Try Asset Panda free for 14 days, and learn how you can give your patients peace of mind and avoid unnecessary medical errors with this powerful, customizable and intuitive asset tracking partner. To learn more, visit assetpanda.com.


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Audra London

Audra London, founder of Conceptual Communications, LLC, has over 10 years of writing, public relations and marketing experience and serves as an expert on press releases, media relations, feature writing, web content and marketing copy.

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