The COA's position on a standardized procedure for reducing the incidence of wrong sided surgery.

Committee on Orthopaedic Practice & Economics (COPE)
Position Paper on Wrong Sided Surgery in Orthopaedics
Prepared for the Canadian Orthopaedic Association June 1994
Paul H. Wright, M.D., FRCSC
Burnaby, BC

Problem:

The wrong side is operated upon.

Plan:

• To develop a reproducible method of operating on the correct side.
• To educate the orthopaedic community about the standardized procedure and accept this as the standard of care.

Discussion

The incidence of wrong sided surgery tends to recur at the same level year after year. This type of malpractice case is extremely devastating to the surgeons involved. No foolproof method can be designed but the optimal one can be standardized to minimize risk to the population and the surgeon.

The procedure needs to be established for the Operating Surgeon. Of those named in these suits, the Operating Surgeon is always found at fault. Most hospitals have an excellent checklist system in place to prevent this occurrence. A modification of their protocol to make it even better is to our benefit.

All the surgeons surveyed used the “best system”. These have all failed when analyzed in the courtroom.

Limb identification must be:

1) Correct
2) Simple
3) Reproducible
4) Not intimidating for the patient
5) Easily seen by all staff and the surgeon

This proposal is a result of common sense, legal opinions, nursing opinions, surgeons' opinions and experience, and an analysis of cases brought to trial.

Proposed Identification of the Correct Side

• Have your office chart with you in the Operating Facility
• Visit your patient preoperatively to mark the limb
• Have the patient identify the site and side to be operated upon.

Mark the specific area to be operated upon with your INITIALS by using a permanent marking pen.

Do not mark the limb in an area that could be draped out during surgery. You must see your initials while you are operating.

Do not operate unless you see your initials before making your incision.

“OPERATE THROUGH YOUR INITIALS”

The marking pen will not alter the infection rate. It is cosmetically transparent in five to seven days. The use of an “X” has failed in these cases. The failure most often results when the patients have crossed their legs, resulting in a perfect reciprocal “X” on their normal leg. You would recognize your initials being backwards. Marking the normal leg with “wrong leg” has failed when it has been incorrectly draped out.

Seeing your initials prepped and visually apparent in the operative field assures you of the correct limb or site before making your incision or puncture. You condition yourself from early on in your training to not start unless you see your initials.

Operating Room Policy

In the Operating Room, the surgeon will not start the case until the initials are identified. In this fashion, markings are not mistakenly covered up with sheets and stockings. Individual protocols for the Operating Room can be worked out according to the present system used in that hospital.

This system will help orthopaedic surgeons immensely with the question of informed consent. The preoperative verbal interchange, leading to the marking of a limb or site, speaks volumes in the courtroom.

“OPERATE THROUGH YOUR INITIALS”

Timetable

• June 1994 - Discussion and approval of the Board of the Canadian Orthopaedic Association.
• July - September 1994 - CMPA Liaison re: education and introduction to the COA Members.
• September 1994 - Formal introduction of the policy statement for the COA Membership. Disbursement of the policy via COA publication.
• January 1995 - Target of training programmes so all residents in Canada are exposed to the process of teaching of this. Assurance that it will be an ongoing and integral part of training of orthopaedic residents in Canada.
• June 1995 - Acceptance as the Standard of Care in Canada for orthopaedic surgeons. Presentation at the COA Meeting in 1995 at a main session or by information booth.
• November 2001 - Update COA Membership on success of position paper via publication in the COA Bulletin.