The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.
Despite efforts to prevent wrong-site surgeries, they continue to occur. This commentary discusses a near miss resulting from human factors and inadequate team communication to underscore the importance of reporting and analyzing incidents to enhance individual practice and teamwork.
By tracking improper surgical bookings and observing time-out procedures, this study measured near misses for wrong-site surgery and provided education about correct procedures when they encountered errors. After this education, surgical booking and time-out procedures improved.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-34.
Wrong-patient and wrong-site surgeries are considered never events, as they are devastating errors that arise from serious underlying safety problems. This study used Veterans Administration data to analyze the broader concept of "incorrect" surgical procedures, including near misses and errors in procedures performed outside the operating room (for example, in interventional radiology). Root cause analysis was used to identify underlying safety problems. Errors occurred in virtually all specialties that perform procedures. The authors found that many cases could be attributed in part to poor communication that may not have been addressed by preoperative time-outs; for example, several cases in which surgical implants were unavailable would have required communication well before the day of surgery. The authors argue for teamwork training based on crew resource management principles to address these serious errors.
Blanco M, Clarke JR, Martindell D. AORN J. 2009;90:215-8, 221-2.
This analysis of wrong-site surgery cases and near misses reported to the Pennsylvania Patient Safety Authority found that many cases involved failure to follow The Joint Commission's Universal Protocol for preventing such errors.
Makary MA, Mukherjee A, Sexton B, et al. J Am Coll Surg. 2007;204:236-43.
Although wrong-site surgeries are rare, they have devastating consequences for patients and are often a harbinger of serious safety problems within an institution. The Joint Commission's Universal Protocol for prevention of wrong-site surgeries requires performing a "time out" before beginning surgery to ensure that all operating room personnel are familiar with the patient, the procedure, their role, and how to respond to complications. In this study, operating room personnel were surveyed regarding their perception of the risk of wrong-site surgery before and after institution of timeouts. Respondents felt teamwork improved and the overall risk for wrong-site surgery decreased after implementing the protocol. An Agency for Healthcare Research and Quality (AHRQ) WebM&M commentary discusses the factors contributing to a near-miss wrong-site surgery.
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