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Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.
Graham C, Reid S, Lord TC, et al. Br Dent J. 2019;226:32-38.
Reporting and avoidance of “never events,” such as a wrong tooth extraction, is important for providing consistently safe dental care. This article describes changes made in safety procedures, including introducing surgical safety briefings or huddles in an outpatient oral surgery unit of the United Kingdom’s National Health Service, that eliminated never events for more than two years.
Nelson PE. AORN J. 2017;105.
The Universal Protocol requires hospitals to adopt time outs as a strategy to prevent wrong-site surgeries. This commentary describes how one organization combined elements of time outs and the surgical safety checklist to augment communication and teamwork in surgical settings. Implementation of the enhanced time out involved targeted education and clarity around surgical roles and responsibilities.
Ragusa PS, Bitterman A, Auerbach B, et al. Orthopedics. 2016;39:e307-10.
Checklists are a popular strategy to improve teamwork and prevent errors. Reviewing the evidence on the use of checklists in surgery, this commentary highlights how the tool and associated time out have reduced some adverse events and helped to manage hierarchy in the operating room.
Collins SJ, Newhouse R, Porter J, et al. AORN J. 2014;100:65-79.e5.
Organizations including The Joint Commission, the World Health Organization, and the Centers for Medicare and Medicaid Services have focused on improving surgical safety. Using Reason's Swiss cheese model, this review analyzes the evidence for surgical checklist implementation to determine its usefulness in preventing wrong-site surgery and recommends tactics to address weaknesses.
Davis JS, Karmacharya J, Schulman CI. J Patient Saf. 2012;8:151-2.
Describing a case of duplicate surgical site markings on a patient's legs, this article reveals how hospital protocol and medical record review prevented wrong-site surgery.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146:1235-9.
This analysis of incorrect surgical procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site, wrong-patient, and wrong-procedure errors compared with the authors' prior study. As in the earlier report, half of the incorrect procedures occurred outside of the operating room. Root cause analyses of errors revealed that lack of standardization and human factors issues were major contributing factors. During the time period of this study, the VA implemented a teamwork training program that has been associated with a significant decline in surgical mortality. The authors propose that additional, focused team training may be one solution to this persistent problem.
Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-73.
This study found that communication breakdowns, inadequate preoperative checks, technical factors, and human error were the primary categories identified in assessing the root causes of wrong-site craniotomy. The authors suggest that the events were preventable had proper compliance with protocols taken place.
Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.
This survey of otolaryngologists found that many respondents had personal experience with wrong-site surgery. Incorrectly labeled or inverted radiographic images were frequently implicated as a contributing cause.
Duthie EA. J Patient Saf. 2010;6:108-114.
This study examines five wrong-procedure cases by applying James Reason’s human error theory, and describes the role of human behavior and cognitive processes in the events. The authors conclude that a systems approach is a more effective prevention strategy than relying on education, counseling, and disciplinary action.
Devine J, Chutkan N, Norvell DC, et al. Spine (Phila Pa 1976). 2010;35:S28-36.
This systematic review of methods to prevent wrong-site surgery discusses the limitations of current preventive strategies, and proposes specific interventions to prevent wrong-site spinal surgery.
Mitchell P, Nicholson CL, Jenkins A. Acta Neurochir (Wien). 2006;148:1289-92; discussion 1292.
The authors interviewed surgeons involved in wrong-site incidents and found that the errors of omission were primarily due to distractions in the operating environment.
Despite a "time out" and having his leg marked by the surgeon, a patient comes perilously close to having surgery on the wrong leg.
Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.
During a hernia repair, surgeons decide to remove a patient's hydrocele, spermatic cord, and left testicle—without realizing that his right testicle had been removed previously.
Trusting his memory more than the chart, a surgeon directs a resident to remove the wrong side on a patient with unilateral vulvar cancer.