Wrong-site surgery
Reviewed by Fiona Rowe

A survey was undertaken with paediatric ophthalmologists to assess a set of factors that influence the risk of wrong-site surgery. The survey specifically considered the preoperative marking process and time-out procedure. It looked at factors included or not included in the University Protocol, surgeon experience and operating environment. The survey of 10 questions had 156 responses accounting for a 15% response rate; 34.6% reported wrong-site surgery and 9% almost did wrong surgery. Preop marking procedure most commonly used a dot mark on the eye and initials. There was a wide range of surgeon experience. Those with <15 years’ experience were more likely to perform wrong-site surgery. In the time-out procedure, multiple lead individuals were most linked to wrong-site surgery. Personal indication by the surgeon of the indicated procedure type was linked with wrong-site surgery. For operating room factors, these were not linked with wrong-site surgery. The authors conclude the likelihood of performing wrong-site surgery can be reduced if the surgeon adheres to a preop marking procedure, if the surgeon is involved directly in all steps of the time-out procedure and with one designated person to lead the process.

Wrong-site surgery in pediatric ophthalmology.
Maloley L, Morgan LA, High R, Suh DW.
JOURNAL OF PEDIATRIC OPHTHALMOLOGY AND STRABISMUS
2018;55:152-8.