Running head: A CULTURE OF SAFETY 1

We Can Do Better: A Culture of Safety for the Patient Concerning Wrong-Site Surgery
Diane A. Gately, Carolyn M. Findlay, Jessica L. Everett, Brandi L. Forrester,
Jennifer A. Derasmo, Gina D. Goad, Mary P. Davidson
Old Dominion University

A CULTURE OF SAFETY 2
We Can Do Better: A Culture of Safety for the Patient Concerning Wrong-Site Surgery
A culture of safety must exist within the operating room (OR), and the OR should
function as a well-oiled machine where the patient's safety is considered the primary mission for
the OR nurse and the surgical team. However, the OR is a complex environment in which
preoperative safety checklists are indispensable. The Joint Commission (TJC) safety goal for
January to June 2013 is aimed at improving the most commonly reported sentinel event of
wrong-patient, wrong-site, wrong-procedure (The Joint Commission, 2013). This national patient
safety goal is relevant to the OR and will be discussed in great detail. This paper focuses
primarily on the changes required to prevent wrong-site surgery.
OR nursing practices need to change as statistics show that approximately 40 times per
week there is a wrong site, procedure, or patient surgery (The Joint Commission, 2011). The first
area that requires attention is in the surgical scheduling department. There must be a surgical
checklist for the scheduling personnel in the surgeons office to follow and communicate to the
scheduling personnel in the OR. This will ensure accuracy of the patient's site, procedure, and
type of surgery to be performed. The OR nurse must then verify all documentation on the chart
to make sure the consent, history, physical, and OR schedule are all in agreement with the type
of procedure to be performed. The OR nurse then ensures the surgeon has marked the correct site
prior to transporting the patient to the OR. The final check is to establish that all personnel are
attentive to the time out. This is the time when all members of the team should remain focused
on what the OR nurse is communicating, and interruptions cannot be tolerated. Wrong-site
surgery can and must be prevented.
Qualitative and Quantitative Data
To adequately assess wrong-site surgeries, essential qualitative and quantitative data need
Rachel AM 6/25/14 8:57 PM
Comment [1]: It appears that your group is
only using 1 level of sub heading. As such, the
1

level subheading is bold, upper/lower case,
bold, and centered, per APA page 62
A CULTURE OF SAFETY 3
to be collected. Qualitative data is information that is observed and provides a description of a
particular subject. This data includes demographics of the patient and the surgical procedure they
underwent, and chart reviews to determine if the history and physical matches the surgical
consent and surgical schedule. Data also need to be collected from the scheduling department to
evaluate their process of scheduling surgeries. It needs to be established if the patients surgical
site was marked correctly and if the surgical time out was performed properly. Further, staff
interviews must be conducted to determine the circumstances surrounding the incident.
Quantitative data is information that can be expressed in numbers and measurements. To
determine quantitative data for wrong-site surgeries, a detailed record must be kept for each
procedure. All surgical cases need to be reviewed for potential or actual occurrence of wrong-site
surgery. These cases can be utilized to determine the rate of wrong-site occurrences in a
particular operating room, the specialties of which it occurs most often, the specific staff
involved, and the time of day the error occurred.
Driving and Restraining Forces
There are many factors, called driving and restraining forces, which work to prevent and
enable wrong-site surgeries. A driving force pushes for positive change, while the restraining
factors counteract. Above all else, simply following the protocols and guidelines with no
deviation can prevent wrong-site surgery from happening (Hanchanale, Rao, Motiwala & Karim,
2014). These protocols include diligently ensuring that the patients health records match the
diagnosis and surgical schedule, and that the laterality matches in all documentation. Guidelines
should be in place with specific instructions that leave no room for varied interpretations among
staff (Hanchanale et al., 2014). Furthermore, the patient should be marked near the intended
incision site, as close as possible, to indicate the site and laterality of surgery. Perhaps the biggest
Rachel AM 6/25/14 8:57 PM
Comment [2]: This paragraph clearly
identifies the qualitative data you would
collect.
Rachel AM 6/25/14 8:57 PM
Comment [3]: Excellent, so it looks like
tracking incidences of actual and potential
WSS as it relates to different variables.
A CULTURE OF SAFETY 4
driving force to prevent surgical errors from occurring is the patients, themselves. Patients
should verify their information on their identity bracelet to check that the correct side is recorded
on the consent form as well as mark the surgical site themselves, along with the surgeon
(Hanchanale et al., 2014). Finally, an environment that allowed patients to ask questions and
speak up if they had any concerns is encouraged.
On the opposing side we have restraining forces that enable potential surgical error.
Hanchanale et al. (2014) identified three factors that contributed strongly to wrong site surgery.
The first factor, and perhaps the most dominate factor, is the environment. ORs are full of
distractions, clutter, and interruptions that impede the correct processes. The second force
identified is the ever present human factor, such as poor communication, fatigue, and time
pressures contributing to medical mistakes. Finally, the patient factor plays an interesting part in
wrong-site surgery. A patients behavioral issues, language barrier, compliance, knowledge
deficit, fear, and disease acuity have been linked to medical errors.
Potential Solutions
There are many potential solutions to avoid wrong-site surgery that are supported by the
data analysis. Firstly, patients should be identified by their hospital bracelet using two identifiers
and asked to confirm the procedure they are scheduled for, verifying the correct patient for the
correct procedure. However, some solutions are complex, involve multiple departments and
staff, and require many steps to ensure no errors occur. These preoperative checklists, or
protocols, involve comparing the history and physical to the surgical schedule, surgical consent,
and other documents. Also, the surgical site, if involving laterality, should be marked by the
patient and surgeon. Intraoperatively, a timeout should be performed prior to incision to ensure
A CULTURE OF SAFETY 5
the correct patient, the correct site, and the correct procedure. Wrong-site surgery can be
prevented by following protocols with no deviation (Hanchanale et al., 2014).
Step by Step Plan
There are three phases of the process that put patients at risk for wrong site surgery:
surgical scheduling, the preoperative (pre-op) area, and the OR. Each phase has the potential for
errors, and communication among staff is crucial in prevention. Patient safety is the goal in
eliminating wrong site surgery; clarifying and improving protocols will assist in reducing risks
and enhance a culture of safety.
Surgical scheduling is where the process begins. Surgeons offices may book procedures
using written booking forms and last-minute verbal bookings, and each office submits their own
booking sheet via fax or email, or calls the OR scheduling department. These variations can
result in incorrect or incomplete procedures, issues with legibility or unapproved abbreviations,
or other inconsistencies. Miscommunication can be reduced by eliminating verbal bookings and
implementing a single, standardized booking form to confirm that the procedure and patient
information is accurate, therefore reducing potential for human error in interpretation and
providing a tracking mechanism. Furthermore, a dedicated fax line for OR bookings would
ensure that information is transmitted to appropriate personnel. Procedures should be verified
with the surgeons office by scheduling staff if there are any questions or clarification needed.
Once the procedure is booked and verified, it should be added to the official OR schedule, which
is printed the day of surgery. A copy of the booking form should be included in the patients
chart, and be easily accessible for the perioperative team to view the day of surgery.
Streamlining the surgical scheduling process would simplify communication and minimize
errors.
A CULTURE OF SAFETY 6
The pre-op area is where patients are registered, prepared, and evaluated before surgery.
In addition to preparing the patient, the pre-op nurse confirms all primary documents are present
and accurate, including the surgical consent and the history and physical. This information is
compared to the OR schedule to clarify any inconsistencies. The OR nurse and the anesthesia
provider then review the chart, interview and assess the patient, and verify the procedure. The
surgeon will examine the patient, address any concerns, sign the surgical consent, and mark the
site before leaving the pre-op area. Typically, all of these tasks are performed quickly in order to
avoid delays, especially for the first surgeries of the day. After the pre-op checklist and nurse
hand off is completed, the patient is transferred to the operating room.
In order to foster a culture of safety, the pre-op area staff must minimize chaos, and
increase coordination and communication. One way of achieving that is by reviewing the
scheduled cases the day before. The pre-op nurse should confirm that the patients record is
complete with a history and physical, pre-op test results, booking form, and surgical consent. If
the consent or booking form does not match the OR schedule, the nurse manager should be
alerted, and the surgeons office contacted to clarify. The patients name and birthdate should be
checked on all documents, identity band, and patient labels to avoid inaccuracies. These
measures can minimize problems and rushing to make corrections on the day of surgery.
Communication is critical between the pre-op nurse and OR team on the day of surgery.
The pre-op nurse interviews and assesses the patient initially, and any discrepancies are reported
to the surgeon, anesthesia provider, and OR nurse. The pre-op protocol should include proper
identification of the patient (using two identifiers), surgical procedure, surgical consent, and
marking of the site by the surgeon and patient if laterality is involved (Hanchanaleet al, 2014).
Additionally, if the patients understanding of the surgical site is different than what is
A CULTURE OF SAFETY 7
scheduled, it should be compared to the history and physical as well as brought to the surgeons
attention. A thorough hand off from the pre-op nurse to the OR nurse would be completed before
the patient is transported to the operating room, and any areas of concern should be addressed
beforehand.
In the OR, the patient is positioned, anesthetized, prepped, and draped. Although the
surgeon, anesthesia provider, and scrub technician should stop all activity and listen while the
circulator performs a time out before beginning surgery, this may not be the reality. Staff
members rush during the time out, which causes them to miss critical steps (Knudson, 2013), and
often, theres a great deal of activity and noise in the OR before surgery begins, including
conversations, music, and movement of equipment. The purpose of time out is for the team to
pause and review significant information regarding the patient and procedure before making the
incision. This is the last opportunity to avoid wrong-site surgery, and staff must be diligent in
eliminating all risks.
Creating an environment where noise and activity cease immediately prior to time out is
critical. Music should be turned off, conversations must end, and everyone stops moving. The
surgical site must be visible to the team after draping, and before time out has begun. The
circulator should not begin the time out until she has the full attention of everyone in the room.
A scripted time out form from AORN may also be helpful to utilize so all steps are covered
(AORN, 2010). The circulator states the patients name with two identifiers, the procedure, site
and laterality, confirms the marking is visible, and asks if anyone has concerns. Surgery does not
proceed until every team member agrees.
Development of protocols and policies in addition to a standard booking forms and a
scripted time out form would be needed to make changes to enhance the culture of safety. In-
A CULTURE OF SAFETY 8
services would be necessary to orient staff to the changes. Although there may be financial
resources required, it would be a worthy investment if it minimizes the risk of wrong-site
surgery. Training staff to communicate effectively, exchange critical information, anticipate risk,
prevent harm, and ensure accuracy can easily improve the culture of safety in the OR.
Change Theory
Change in the OR begins with change agents, the individuals or groups that work and
plan the change (Blais & Hayes, 2011). In the OR the change agents are the nurse managers,
surgeons, and administrative leaders. It is pivotal that the change agents work as a unified team
in developing an action plan. They need to embrace a change theory that reflects their intentions
and goals, and provides a framework for innovation. The change theory acts as a mechanism for
the modification to occur.
The change theory that seems most applicable to the ORs goal of increasing patient
safety is George Lippitts Seven Phases of Planned Change. Lippitts theory focuses on what
change agents must do as opposed to other change theories that focus on the evolution of change
(Blais & Hayes, 2011). The seven phases are as follows: diagnose problem; assess problem;
assess change agents motivation and resources; select progressive change objects; choose
change agent role; maintain change; and terminate helping relationship (Blais & Hayes, 2011).
Once OR leadership recognizes that the safety of surgical patients in their OR is at risk,
they have diagnosed a problem and can begin to remedy it. Together, the next two steps assess
the problem and the change agents motivations and resources. If the OR team recognizes that its
current procedures and protocols do not currently protect surgical patients, it is their duty to
assess the problem and motivate other staff members to improve. The OR leadership team needs
Rachel AM 6/25/14 8:57 PM
Comment [4]: Is it possible to have change
agents in the staff ranks?

A CULTURE OF SAFETY 9
to determine what resources need changes, including but not limited to: staff education,
technology updates, supplies, research on best practices, and future protocol manuals.
Once the problem has been identified and analyzed, the fourth phase is enacted: selecting
the progressive change objects (Blais & Hayes, 2011). The OR leadership, upon completion of
data analysis, takes goals and objectives and implements them into concrete actions that allow
for change. The fifth phase is to establish change agents role. This will be the greatest hurdle
for the OR leadership. The OR leaderships role as a change agent will be to lead and
communicate to the staff, provide education, and support to all staff. It is crucial that the OR
leadership educate their staff members on the problem, providing them with current data
regarding wrong site surgeries, and ultimately persuading them to embrace changes aimed at
ensuring patient safety.
Once the changes have been made and implemented, it will be important to maintain
these changes and evaluate their effectiveness. Positive results will provide staff with feedback
and motivation to continue on with the implemented changes. Lippitt recognizes that change
needs to take hold, be maintained, and stabilized within an organization (Blais & Hayes, 2011).
The OR leadership must be vigilant that staff does not go back to their old ways or habits. Staff
must understand that deviating from the planned changes and going back to old ways jeopardizes
the OR teams ability to provide safe and effective healthcare.
Evaluation Process and Measurable Outcomes
A root cause analysis is an essential process to identify the factors leading to a wrong-
site surgery as, according to Datillo and Constantino (2006), The most fundamental reason for
the failure or inefficiency of a processis referred to as a root cause, (p.221).
A CULTURE OF SAFETY 10
Evaluating the staffs knowledge in the prevention of wrong-site surgery is a key step. If
there is a knowledge deficit, then the behavior will continue, thus increasing the risk of a wrong-
site surgery occurrence. In addition, audits should be performed to evaluate the staffs adherence
to proper procedures.
Measurable outcomes may include: the OR nurse properly performing two-patient
identification and checking that the patients history is consistent with the OR schedule, patients
consent is obtained and on file, and patients verbal understanding of procedure is documented.
The physician and the patient mark the site of surgery if laterality is involved, and all OR
personnel remain attentive during the time-out procedure.
Stabilizing the Change
The first step to stabilizing the change is to analyze whether a positive change occurred.
Providing the staff with a post-test to assess their knowledge after providing education, as well as
reviewing audit results and providing positive feedback for the time frame since education
occurred are useful strategies. This can serve as a motivating factor to maintain current practice.
Staff should also recognize consequences if the change does not occur. Incentives can be put into
place to encourage compliance, such as recognition for catching errors that prevent wrong-site
surgery.
The Role of Leadership
Management plays a crucial role in implementing change, especially on patient safety
issues as severe as wrong-site surgeries. Management retains the role of implementing measures
to prevent continued patient harm. Proper enforcement of these policies requires that staff
working in the OR be held accountable by their unit or department supervisors for when lapses in
protocols occur. This type of organizational change requires discussion and training prior to
A CULTURE OF SAFETY 11
implementation, as a great deal of responsibility lies on the employees. A checklist style protocol
would be beneficial in marking each individual section for assessment and completeness. The
use of a rational-empirical approach would facilitate change by the staff through thorough
education on the merits of the new policies. Additionally, nursing staff can be included in the
formulation of said checklists and have input on its construction.
Success of the new policies lies on the department staff, such as OR nurses. The use of
random audits can allow for the unit manager or supervisor to determine which staff need
additional education on the new policies or if there is an issue with the checklist itself.
Department lunches, parties, and other awards may be adopted to encourage its use, as well as
recognize the people working toward the overall goal of wrong-site surgery prevention.
There should be no reason for a patient to receive the wrong surgical procedure because
of the suggested solutions mentioned in this paper. Policies requiring two patient identifiers,
consent forms, proper marking of the site to be operated on, and a time out performed before
surgery begins are all set in place to protect patients rights as well as their bodies. Safety is
everyones top priority and wrong-site surgery is preventable.








A CULTURE OF SAFETY 12
References
Anders, R. & Hawkins, J. (2006). Mosby's nursing leadership & management online: A work
text and online course. St. Louis, MO: Mosby Elsevier.
AORN Comprehensive Surgical Checklist (2010). Retrieved from
http://www.aorn.org/Clinical_Practice/ToolKits/Correct_Site_Surgery_Tool_Kit/Compre
hensive_checklist.aspx
Blais, K., & Hayes, J. (6th Ed.). (2011). Professional nursing practice concepts and perspectives.
Upper Saddle River, NJ: Pearson.
Dattilo, E., & Constantino, R. (2006). Root cause analysis and nursing management
responsibilities in wrong-site surgery. Dimensions Of Critical Care Nursing, 25(5), 221-
225.
Hanchanale, V., Rao, A. R., Motiwala, H., & Karim, O. M. A. (2014). Wrong site surgery! how
can we stop it?. Urology Annals, 6(1), 57-62. doi: 10.4103/0974-7796.127031
Knudson, L. (2013). Time out remains key weapon in fight against wrong-site surgeries.
AORN Journal, 97(6), C5-6.
Steelman, V. M., & Perkhounkova, Y. (2013). Priority patient safety issues identified by
perioperative nurses. AORN Journal, 97(4), 402-418.
The Joint Commission Center for Transforming Healthcare (2011). Reducing the risk of wrong
site surgery. Retrieved from http://www.centerfortransforming
healthcare.org/assets/4/6/CTH_WSS_Storyboard_final_2011.pdf.
The Joint Commission (2013, October). Sentinel event statistics for the first half of 2013.
Retrieved from http://mail.tcrespite.com/TJCNewsletters/Perspectives/Perspectives-
10.pdf
Rachel AM 6/25/14 8:57 PM
Comment [5]: Per APA page 214-215, not
necessary to put the date it was received. If
you do include a date, it would be the date of
the posting
A CULTURE OF SAFETY 13
(2013). 6 tips to avoid wrong-site surgery. Same-Day Surgery, 37(7), 80-81. Retrieved from
http://eds.b.ebscohost.com.proxy.lib.odu.edu/eds/pdfviewer/pdfviewer?sid=52cd57e2-
0924-479b-9674-96d354b52b28@sessionmgr114&vid=4&hid=107

A CULTURE OF SAFETY 14
Honor Code
"I pledge to support the honor system of Old Dominion University. I will refrain from
any form of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as
a member if the academic community, it is my responsibility to turn in all suspected violators of
the honor system. I will report to Honor Council hearings if summoned."

Mary P. Davidson, Jennifer A. Derasmo, Jessica L. Everett, Carolyn M. Findlay,
Brandi L. Forrester, Diane A. Gately, Gina D. Goad


Joint Commission Safety/Performance Improvement & Change Theory
Group Assignment
Assignment Grading Sheet
Grading Criteria % Comments Points
Identify a TJC safety goal that is relevant to
an area of concern at your place of
employment or clinical rotation.
Describe a situation in the workplace or
nursing practice that needs change.
10 Excellent, well written and
concise. Grabs the readers
attention
10
Identify the data that should be collected-
qualitative and quantitative, and identify
the driving and restraining forces
10 Good discussion of
quant/qual data and
driving/restraining forces.
10
Identify potential solutions that would be
supported by the data analysis
5 A variety of solutions are
presented
5
Describe the step by step plan that would
be implemented to address the
problem. Include available and needed
resources including finances.
20 A variety of steps and pieces
and parts to this complex
issue are presented.
Financial resources are
presented, text alludes to
resources for inservices and
training. What is missing in
the discussion of resources
are both material and human
resourceswill you need
paper checklists or computer
based checklists, if
computerized resources in
informatics and IS will be
15
A CULTURE OF SAFETY 15
needed, paper based
resources will likely need
approval and development,
posted signs or placards for
time outs or will need
developmentwho are the
human resources that will put
these together? Will you
have staff, physician,
coordinator staff as
communication leaders?
Additional discussion of
material/human resources is
needed.
Using an appropriate change theory,
describe how this theory could be used
to implement the change process
10 Lippitts change theory is
described in detail.
10
Describe the evaluation process including
measurable outcomes.
10 Evaluation of specific
behaviors (checking two-
patient identifiers),
documentation (conset), and
even patient education are
described as outcome
measures.
10
Discuss the plan for stabilizing the change 5 Variety of activities to
maintain/stabilize change are
described.
5
Describe leaderships role in this PI
process. Identify key players who
would be beneficial for success
10 Formal leadership role is
described, engagement of
direct bedside staff is also
covered.
10
Correct grammar, essay writing, spelling
and punctuation.
10 Minimal/no grammar, spelling
issues noted.
10
Correct use of APA format including
adherence to page limit (10 pages).
Include minimum 4 textbook or journal
articles as references. Include a copy
of the rubric and honor code. Submit
through SafeAssign.
10 Subheading issue and
references for internet
inconsistent. Otherwise,
minimal issue.
9
Final Grade: 100 94

A CULTURE OF SAFETY 16
Group 3, excellent paper. The major content point deduction was related to description of
resources. You mentioned financial and alluded to inservice/educational resources needed,
however, additional discussion of any material or human resources is needed as well. I provided
some feedback above in the rubric. Some additional thoughts for consideration are in the paper
via comments with track changes. Slight APA issue, point deduction could have been more
significant. Watch your subheadings and watch the reference list. Otherwise, good job.