Circulation 36,825 • Volume 17, No. 3 • Fall 2002

Current System May Miss the “Mark”

To the Editor

At our surgery facility the preoperative nurses routinely have the patient mark “No” on the non-operative side for procedures such as carpal tunnel releases, shoulder cases, and so forth. I have welcomed this because it prevents the performance of surgery on the wrong side . . . or does it? I recently gave general anesthesia to a patient having a knee-scope. The surgeon applied the tourniquet, injected local anesthetic into the joint and the nurse was prepping the knee when I happened to be reviewing the surgeon’s history and physical (to record the correct diagnosis on my billing sheet). At this point I told the nurse that the H&P said left knee although she was prepping the right knee. The lively voices of OR personnel were immediately changed to somber tones and the nurse dejectedly admitted, “Look, I’m prepping right over the ‘No.’”

Many lessons can and should be taken from this case, but the one I’d like to emphasize is this: safety procedures are helpful, but we must not rely on them. Instead, I think, we must promote an overall culture of safety: attitudes, training, procedures, and common sense that combine to create a safe, not fool-proof, perioperative environment for our patients. I would like to ask the APSF to consider promoting the term “culture of safety” and invite further discussion on this concept which obviously ties into the mission of the APSF. I also suggest that the APSF establish a regular column in this newsletter for members to share mishaps or near misses, such as this one, along with comments for the benefit of others.

Thank you.
Name Withheld on Request.

Editor’s Note: The APSF Newsletter continues to welcome reports of mishaps and near misses.