How can wrong-site surgeries, such as operating on the incorrect leg during a total knee replacement, be prevented?

Prevention of Wrong-Site Surgery in Total Knee Replacement

Proper preoperative site marking by the surgeon, combined with multiple independent verification steps and a formal timeout procedure, is the cornerstone of preventing wrong-site surgery. 1

Critical Prevention Components

Preoperative Verification and Marking

• The surgeon must personally discuss the planned procedure with the patient and mark the appropriate operative site before any sedation or anesthesia is administered 1, 2
• The informed consent form must explicitly describe the procedure and operative site without abbreviations 1
• Prior to administering any medications, nursing staff must independently ask the patient which site is to be operated on to ensure accuracy 1
• Preoperative nursing staff must verify that the patient's verbal response, informed consent, and physician's orders all match for the operative site 1
• For bilateral sites, standardized coding should be used (Right=1, Left=2, Bilateral=3) 1

Multiple Independent Checks

• The patient is a more reliable source of accurate information than documents alone, and preoperative verification is the most effective step in preventing wrong-site surgery 2
• Discrepancies among the operative record, consent, and surgeon's history and physical examination should be resolved prior to the day of surgery 2
• Office chart notes must be physically available in the operating room for reference 1
• Patients and circulating nurses are the surgeon's best allies in catching errors, with patients preventing 57 wrong-site surgeries and nurses preventing 30 in one state-wide analysis 3

Formal Timeout Protocol

• A formal timeout must be performed verifying the patient's identity, planned procedure, operative site, and any implants or special equipment required before incision 1
• The timeout must be conducted as a structured closed-loop communication process where information is stated and verbally confirmed by all team members 1
• The circulating nurse must ensure the operative plan is visible so the surgeon can read it while gowned and gloved 1
• The patient's name, operative site, and any implant information should be written on a visible whiteboard in the operating room 1

Critical Pitfalls to Avoid

Timing Issues

• Many errors occur before the formal timeout, particularly during patient positioning (20 cases) and anesthesia interventions (29 cases) that happen before verification processes 3
• Marking the operative site gives patients a voice after they are sedated or anesthesia is induced, preventing errors that occur once the patient can no longer communicate 2

Process Failures

• Not verifying consents (22 cases) or site markings (16 cases) contributed to wrong-site surgery in state-wide reporting 3
• Interestingly, 31 formal timeout processes were unsuccessful in preventing wrong-site surgery, indicating that the timeout alone is insufficient without proper preceding verification steps 3
• Site markings must be visible after draping, yet only 55.6% of marked cases maintained visible markings 4

Team Communication

• Junior members of the operating room team must be made comfortable speaking up if concerned about any discrepancy 2
• The operating surgeon should personally mark the patient in the majority of cases rather than delegating this critical task 4

Why the Nurse Must Speak Up

The scenario described—where a nurse knew but kept quiet—represents a catastrophic failure of safety culture. 1 Establishing a culture of respect and collaboration that prioritizes patient safety is essential, with a "just culture" approach to error reporting that encourages transparency rather than punishment 1. Non-punitive quality assurance systems for incident reporting are essential for continuous improvement 1.

Implementation Requirements

• Develop written policies specifically addressing wrong-site surgery prevention 1
• Provide adequate training for new staff on wrong-site prevention protocols 1
• Use simulation-based training to practice timeout procedures and closed-loop communication 1
• Conduct regular audits of compliance with site verification protocols 1
• Wrong-site surgery occurs an estimated 40 times per week in U.S. hospitals, with lower extremity procedures being the most common (30%), making total knee replacement a high-risk procedure requiring uncompromising vigilance 3, 5