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Publication Type: Patient Safety Alert
Single or Multiple Incident: Multiple
Date: 12/16/2019 12:00:00 AM
Country: South Korea
This alert describes patient safety incidents of surgery being performed on the wrong body part. Contributing factors were wrong surgical site marking, wrong check of the examination image (X-ray), and removal of a surgical marker before the procedure. Two cases are described. Recommendations focusing on surgical site marking and use of time out procedures are provided. Included in the alert are an example of an operating room performing a time out and guidelines for marking surgical sites.

Additional Details

Device:
indelible pen, bracelet, wrist band

Rules / Policies / Procedures
  1. Mark a surgical site by an operating surgeon. - Use an indelible pen so that the site marking is not erased, even when the skin is sterilized.
  2. Mark a surgical site when it needs to be identified as left/right or a multiple structure or multiple level - Do not mark “X” or “No.” - Mark “Rt,” “Lt,” “Both,” or “Left” near the incision. In the case of the spine, mark the spine’s general level (e.g., L2) to avoid confusion.
  3. Check and mark a surgical site in the presence of the patient (caregiver, if it is difficult to communicate with the patient).
  4. After marking a surgical site, fill out the surgical site mark confirmation and let the patient sign the confirmation. - Check the surgical site when the surgery consent form and the surgery schedule are entered.
  5. Before anesthesia, before an incision, and after surgery but before entering the recovery room, all staff involved in the surgery should check the following items after temporarily stopping their work. - Check if he/she is the surgical patient - Check if the surgery/procedure is correct - Check if the surgery/procedure method is correct
  6. In the case of joint treatment, repeat this process whenever a surgical team is changed.

Wrong surgery because of a wrong surgical site marking