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National Patient Safety Agency Protocol for Pre-operative Site Marking
Submit responseSir
Fraser and Adams's commentary suggests that the most important method of reducing wrong site surgery is to have a consistent and robust protocol (1). They also give examples of numerous factors that disrupt the smooth running of the system and increase potential for harm. In March 2005, the National Patient Safety Agency produced a Patient Safety Alert in an attempt to standardise preoperative marking and marking verification (2). The NPSA checklist requires four signatures before the operation can proceed: the surgeon's signature to indicate that the correct side has been marked, followed by signatures of the ward nurse, operating surgeon and theatre staff to confirm the validity of the skin mark against the supporting documentation.
We feel that the key to safe clinical practice is to use a procedure that is simple and consistent without relying on many individuals and we have several concerns about the NPSA checklist. Changes to a routine, interruptions, distractions or too many forms and procedures may actually detract from safe practice. The NPSA's requirement to complete and sign yet another sheet of paper is unnecessary, and may detract from a full discussion with the patient, the correct choice of lens implant, and safe clinical practice. A series of signatures on the form can confer a false sense of security: an initial error may be compounded. It becomes less likely with each confirmatory signature that an individual will notice or question a mistake. This explains why errors still occur in hospitals where this policy is followed to the letter. The ultimate responsibility for the patient lies with the operating surgeon, and it is vital that surgeons do not neglect their usual methods for checking the correct site. Perhaps because of the absence of an evidence base, the NPSA acknowledges that the checklist need not be followed if robust alternatives for ensuring correct site surgery are already in place. That there are so few incidents of wrong site surgery in ophthalmology is testament to the importance placed on individual responsibility and the success of these robust alternatives.
References
(1) Fraser SG, Adams W. Wrong Site Surgery. Br J Ophthalmol 2006; 90:814-816
(2) The National Patient Safety Agency and the Royal College of Surgeons of England. Patient Safety Alert 06: correct site surgery http://www.npsa.nhs.uk/site/media/documents/ 883_CSS%20PSA06%20 FINAL.pdf
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Patient safety and ophthalmic surgery marking - which side are you on?
Submit responseDear Editor,
We read with interest the paper by Fraser and Adams[1], which suggested many reasons for the wrong site surgery and also suggested ways of preventing it. We carried out semi-structured interviews of ophthalmic surgeons (Consultants and Specialist registrar) throughout Scotland by telephone on their current practices and attitudes relating to preventing wrong side surgery in ophthalmology and describe a risk-stratified approach in side marking based on individual patient factors that may encourage wider acceptance without compromising patient safety.
Wrong site surgery, while not common, may be the most devastating of all surgical errors for patients and is likely to result in claims being made against doctors. The Scottish Health Service Central Office only held case descriptions for wrong site surgery only for the years from 1996-1998 and then since 2004. During these four years they dealt with 22 claims relating to wrong site surgery, two of which were in ophthalmology. The first was a DCR operation to unblock a right tear duct but the operation was carried out on the left side. The second case was in squint surgery where there was division of the wrong eye muscle. Much research into the root cause of medical mistakes has found miscommunication to be the key factor.[2,3,4]
In ophthalmic surgery there is currently no single standard method for ensuring the correct side is operated on. Several agencies, including the Joint Commission on Accreditation of Healthcare Organisations (JCAHO), the Association of OR Nurses (ACORN) and the National Patient Safety (NPSA) have created 'best practice' recommendations on how best to avoid wrong site surgery.[5,6,7] All of these make the recommendation that surgeons mark the side to be operated on to improve patient safety. We conducted a survey to ascertain whether or not these 'best practice' guidelines are currently being implemented by surgeons in Scotland and if not, the reasons for this, and also to ascertain surgeons' attitudes towards marking.
In the survey out of the 93 surgeons contacted, 69 were available to be interviewed. This included 60 consultants and 9 registrars. This gives a 65% response rate of consultants and Specialist registrars in Scotland.
It was found that non-compliance with side marking was common: described in 48% of the group. A number of reasons for the non- implementation of these guidelines were cited by respondents, the most common of which was concern that side-marking may bypass the established multi-step process of checks and risking an increased likelihood of surgical errors. Research involving both field observation of the surgical process and interviews of health professionals found that the most important barrier to implementing wrong site surgery guidelines was the failure to account for the dynamic work environment.8 The results of this survey would seem to show that this is the case in implementing the recommendations in ophthalmology.
Having a uniform practice adhered to by all surgeons would be ideal. Therefore, we suggest a risk-stratified approach in side marking based on individual patient factors that may encourage wider acceptance without compromising patient safety. A red/amber/green system based on risk has been used in other areas of healthcare. The risk colour code would be assessed by staff at pre assessment and flagged to the patient and on the clinical records. Red would require patient side marking to be carried out prior to pre-medication, amber for marking in the anaesthetic room and green for patients in whom pupillary dilatation indicates the side for surgery in lieu of a pen marked side - patients who are complis mentis for day care cataract surgery with consent taken at pre-assessment would be coded green. Applying a uniform standard of care by adopting this traffic light approach in marking practice could be a major step forward in achieving compliance with NPSC and reducing the risk of wrong eye surgery. Establishing this practice amongst the consultants is likely to cascade to their trainees. Evidence of improved adherence to side-marking protocols would then need to be gathered by further audit cycles.
References
1 Fraser SG, Adams W. Wrong site surgery. Br J Ophthalmol 2006; 90:814-816
2 The National Association of Theatre Nurses (NATN). Safeguards for Invasive Procedures: The Management of Risks (1998). NATN Harrogate, Yorkshire. [Replacing Theatre Safeguards (1998) The Medical Defence Union (MDU), Medical Protection Society (MPS), Medical and Dental Defence Union of Scotland (MDDUS), NATN and the Royal College of Nursing (RCN)].
3 Joint Commission on Accreditation of Healthcare Organisations. Lessons learned: wrong site surgery. Sentinel event Alert Aug 1998 vol28: 6
4 Woolf. S, Kuzel. A, Dovey. S, Philips. R.L. A String of Mistakes: The importance of Cascade analysis in Describing, Counting, and Preventing Medical Errors. Ann Fam Med July 2004;vol 2:4
5 Joint Commission on the Accreditation of Healthcare professionals. Sentinel event policy and procedures [online] Available from Internet: (accessed May 2006)
6 ACORN Position statement on correct site surgery. By Association of OR Nurses (ACORN). Available online (accessed May 2006)
7 National Patient Safety Agencies and Royal College of Surgeons of England: National Patient Safety Alert 06. Joint Commission on Accreditation of Healthcare Organisations. April 2003.
8 Rodgers. M, Richard. I, Bower. R et al. Barriers to implementing wrong site surgery guidelines: A cognitive work analysis. IEEE November 2004; Vol 34 757-763.
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