Nationwide, the number of patients receiving procedures on the wrong side, or the wrong site, is estimated to be as high as 40 each week.
Jefferson University Hospital took part in a recent effort to lower that incidence.
Rich Webster, Jefferson’s vice president of perioperative services, describes the imaginary case of Mr. Jones’ hip replacement.
A nurse turns off the radio and requests silence, he says. The anesthesiologist would then enter the operating room.
“Good morning, my name is Dr. Smith. Today we are doing a procedure on Mr. Jones. He’s have a right hip replacement,” he says.
The moment Webster is describing is called a time out.
Then, he says, the room acknowledges and confirms that everyone is in agreement: “Yes, this is Mr. Smith and we are doing a right hip replacement on him.”
“Then, immediately before they would hand a scalpel to the surgeon, they again stop to announce, ‘This is Mr. Smith, he’s having a right hip replacement today.’ “
Jefferson recently teamed up with the Joint Commission Center for Transforming Healthcare to reduce the opportunities for wrong-side surgery.
Taking real time for time out was one improvement they made. Silence, the full attention of operating room staff, repeating the site location–Webster says these simple changes to protocol made a difference.
“As we examined each stage of the process, we were able to reduce the number of opportunities that we found for possible error significantly,” he said. “In some areas, I think we cut them in half.”