mation. Although this never occurred, Mrs L assumed that it meant her surgery date and time were approved.
Mrs L presented to the ambulatory surgical center (ASC) for an abdominal hysterectomy at 9 AM on the suggested date. On arrival, the ASC secretary asked Mrs L to verify her name, date of birth, and surgical procedure. The secretary noted that the surgical schedule listed Mrs L as being scheduled for a “vaginal” hysterectomy. The secretary immediately notified the OR manager of the discrepancy in procedure type. The OR manager then notified the assigned circulating nurse. The nurse and assigned scrub person worked cooperatively to repick a case cart for the corrected procedure, repositioned the OR bed, and reset up the OR for an abdominal rather than a vaginal hysterectomy.
This error resulted in a surgical delay, which frustrated the surgeon. Although the patient understood the error and delay, she became very anxious. Mrs L’s family also was very anxious and required reassurance that the correct surgery was going to take place.
Using the SBAR communication technique, the preoperative nurse gave the following hand-off report to the circulating nurse.
• Situation—This is Mrs L, date of birth 9/21/42, a 66-year-old patient of Dr H. She has been preoperatively prepared for an abdominal hysterectomy. All documentation, laboratory reports, and signed informed consent are present in the record. Mrs L’s history and physical examination are on the chart and have been updated.
• Background—For the past three months, Mrs L has experienced postmenopausal bleeding. Furthermore, she has a medical