The Challenge:

Wrong Site Surgeries used to be considered rare events, but now we are learning more about their prevalence. Since December 31, 2007, the Joint Commission’s Sentinel Event Statistics indicate 651 wrong site surgery events have been reported. Of all the sentinel events (unexpected occurrences involving death or serious physical or psychological injury), wrong site surgery is the number one most frequently reported event and represents 13.1 percent of all errors reported to the Joint Commission.

The Impact:

Medical liability carriers paid an average of $48,087 to patients for wrong-site orthopedic surgery claims and an average of $76,167 for patients for wrong-site surgery in other specialty areas.

The Prevention Above All Intervention:

The Medline S.T.O.P drape incorporates a “Time Out” sticker strip that must be removed prior to the surgical case and provided to the circulating nurse to be placed on the patient’s chart. The sticker is in the shape of a red stop sign and tells the staff to stop, forcing them to perform the time-out required prior to beginning surgery. The sticker provides a location to write and confirm the patient’s name, procedure, site and side, date, time and surgeon’s initials. By requiring the surgeon to initial the sticker, the surgical team is again reminded to perform the time-out immediately prior to the incision, thus encouraging improved compliance with performing the time-out procedure.