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Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?
Seiden SC, Barach P. Arch Surg. 2006;141:931-939.
Although instances of wrong-site, wrong-procedure, and wrong-patient adverse events (WSPEs) have been widely publicized, the true incidence of such errors remains unclear. A
prior study
indicated a rate of approximately 1 case per 112,000 surgeries, but WSPEs may occur in the outpatient setting or in ambulatory surgery as well. In this study, the authors reviewed four databases to determine the incidence of all WSPEs, including procedures performed outside the operating room. Data from both mandatory and voluntary reporting systems indicates that approximately 1300 to 2700 WSPEs occur yearly, with many occurring during outpatient procedures. The authors argue that all WSPEs should be considered preventable, and recommend reporting and prevention standards for reducing such errors.
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STUDY
Operating room briefings and wrong-site surgery.
Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.
COMMENTARY
Right? Left? Neither!
Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.
COMMENTARY
Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.
Knight N, Aucar J. Am J Surg. 2010;200:803-807.
REVIEW
Avoiding wrong site surgery: a systematic review.
DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.
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Resource Type
Study
Setting of Care
Operating Room
Ambulatory Clinic or Office
Target Audience
Physicians
Nurses
Facility and Group Administrators
Risk Managers
Quality and Safety Professionals
Clinical Area
Medicine
Surgery
Safety Target
Wrong Patient
Wrong-Site Surgery
Wrong-Site Surgery
Error Types
Epidemiology of Errors and Adverse Events
Approach to Improving Safety
Error Reporting
Learning Organization
Technologic Approaches
Origin/Sponsor
United States of America