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PSNet: Patient Safety Network
Journal Article
Study

Surgical case listing accuracy: failure analysis at a high-volume academic medical center.

Cima RR, Hale C, Kollengode A, et al. Archives of surgery (Chicago, Ill. : 1960). 2010;145:641-6.

Wrong-site surgeries are a rare yet devastating complication for patients. Despite efforts to reduce the risk through adoption of Joint Commission’s Universal Protocol and implementation of briefings, these events continue to occur. This study explored a less understood risk for wrong-site surgery by focusing on the documentation transition from outpatient settings to the operating room. Investigators found a 1.4% error rate between the surgical listing and the performed procedure. While no wrong-site surgeries occurred, there were nearly 800 cases where this potential was noted and caught prior to surgery. The error rate was constant across specialties and most frequently associated with mistakes in laterality. After implementation of an electronic and standardized surgical listing form, the error rate was significantly reduced. Past AHRQ WebM&M commentaries have discussed the factors contributing to a near-miss wrong-site surgery and the role of time outs.