The definition of wrong-site surgery includes operating on the wrong site, performing the wrong procedure, or performing a procedure on the wrong person. In ophthalmology, the definition includes operating on the wrong eye or performing the wrong procedure, including implantation of a lens whose style and/or power differs from that chosen during preoperative surgical planning. For example, inserting a monofocal lens during cataract surgery, when the plan was to implant a premium intraocular lens, is considered the wrong procedure.
In 2004, the Joint Commission enacted the Universal Protocol (www.jointcommission.org/standards_information/up.aspx), which was developed to eliminate wrong-site surgery in the United States. The Universal Protocol includes several key elements:
agreeing on and documenting the procedure to be performed (typically done on the surgical consent form)
marking the surgical site in the preoperative period (done by a designated member of the team, typically the surgeon)
pausing before the beginning of surgery (performing a time-out) to verify that all members of the surgical team agree that this is the correct patient and correct procedure; that the necessary equipment is present, including implants; that the patient is correctly positioned; that the medical information on the patient, including x-rays, is for the correct patient; and that appropriate preoperative antibiotics, if indicated, have been given.
To reduce potential errors, including performing surgery on the wrong patient, 2 unique patient identifiers are required to be confirmed by the surgical team before the initiation of surgery. These identifiers, used during the time-out, include name, date of birth, and medical record number. For the time-out to be effective, it is important that members of the surgical team feel empowered to speak up and invoke a hard stop if they do not agree that all elements of the Universal Protocol have been satisfied. Wrong-site surgery is considered a sentinel event and, in many states, must be reported to the state board of medicine.
The AAO has a wrong-site-wrong-IOL checklist that surgeons may find very useful and can be used to ensure that the necessary steps are adhered to in every patient before cataract surgery to eliminate the risk of wrong-site surgery or wrong-IOL implantation. This type of checklist can be adapted/modified to any other type of surgery.
Excerpted from BCSC 2020-2021 series: Section 1 - Update on General Medicine. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.