Verify That Correct Patient Is Present for Surgical Procedure

Two items included on the surgical ‘never events’ list include:

1. a surgical procedure performed on the wrong patient; and
2. the wrong
   surgical procedure performed on a patient.

Serious preventable medical errors associated with surgical procedures can
occur while caring for inpatients and outpatients. The ‘never events’ for
surgical procedures includes a list of reportable errors that contains several
items. Surgery performed on the wrong patient is one such item. This event
occurs less frequently than does surgery being performed on the wrong body
part.

How can a surgical procedure be performed on the wrong patient? Well, with
certain kinds of simple surgical procedures, a hospital or clinic will
schedule a large number of patients during the course of the day who are all
undergoing the same kind of procedure with minor variations.

On occasion, patient number four will be in the chair when you are expecting
to see patient number three. The health care team must ensure that the right
implantables and the right equipment are available for that patient.

One type of surgery for which this is an area of concern is ophthalmic surgery
for lens implantation. The health care team must ensure that they have the
right patient and the right implantable for that particular procedure. We are
familiar with a number of situations where, just before implanting the lens,
the surgical team realized that the person in the chair was different than the
patient they were expecting.

Another item on the surgical ‘never events’ list is the wrong surgical
procedure performed on a patient. This item is distinct from the wrong patient
discussed above. A good example of this surgical complication is when an L3-L4
procedure is performed on a spinal surgery patient who is scheduled for an L2-
L3 procedure.

An example of another similar situation would be a patient coming in for
excision of a breast mass and the patient has several areas of concern. This
patient is scheduled for excision of a mass at the two o’clock location, but
excision is performed at the four o’clock or 10 o’clock position. These may be
related lesions, but the wrong procedure is performed.

Perhaps it is true that the patient needed to have these other lesions
removed, but that was not the plan for the day, and the wrong lesion was
excised at that time. In these situations, people are very emotional and
upset. Focus on the patient first and then figure out why the error happened
later.

Reference:
Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Never Events:
Wrong Surgical Patients and Wrong Surgical Procedures.