@article{4419,
  author = {Kristen Miller and Maisha Mims and Douglas E. Paull and Linda Williams and Julia Neily and Peter D. Mills and Caryl Z. Lee and Robin R. Hemphill},
  title = {Wrong-side thoracentesis: lessons learned from root cause analysis.},
  abstract = {<p><b>IMPORTANCE: </b>Despite the recognized value of the Joint Commission's Universal Protocol and the implementation of time-outs, incorrect surgical procedures are still among the most common types of sentinel events and can have fatal consequences.</p><p><b>OBJECTIVES: </b>To examine a root cause analysis database for reported wrong-side thoracenteses and to determine the contributing factors associated with their occurrence.</p><p><b>DESIGN, SETTING, AND PARTICIPANTS: </b>We searched the National Center for Patient Safety database for wrong-side thoracenteses performed in ambulatory clinics and hospital units other than the operating room reported from January 1, 2004, through December 31, 2011.</p><p><b>MAIN OUTCOMES AND MEASURES: </b>Data extracted included patient factors, clinical features, team structure and function, adherence to bottom-line patient safety measures, complications, and outcomes.</p><p><b>RESULTS: </b>Fourteen cases of wrong-side thoracenteses are identified. Contributing factors included failure to perform a time-out (n=12), missing indication of laterality on the patient's consent form (n=10), absence of a site mark on the patient's skin within the sterile field (n=12), and absent verification of medical images (n=7). Complications included pneumothoraces (n=4), hemorrhage (n=3), and death directly attributable to the wrong-side thoracentesis (n=2). Teamwork and communication failure, unawareness of existing policy, and a deficit in training and education were the most common root causes of wrong-side thoracentesis.</p><p><b>CONCLUSIONS AND RELEVANCE: </b>Prevention of wrong-site procedures and accompanying patient harm outside the operating room requires adherence to the Universal Protocol and time-outs, effective teamwork, training and education, mentoring, and patient assessment for early detection of complications. The time-outs provide protected time and place for error detection and recovery.</p>},
  year = {2014},
  journal = {JAMA Surg},
  volume = {149},
  pages = {774-9},
  month = {08/2014},
  issn = {2168-6262},
  doi = {10.1001/jamasurg.2014.146},
  language = {eng},
}