Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.
Approach to Improving Safety
Efforts to prevent wrong-site and wrong-patient surgical errors (WSPEs) initially focused on procedural disciplines and operating room procedures. However, this analysis of WSPEs that were voluntarily reported to a Colorado malpractice insurance company database found that a significant proportion of WSPEs were committed by physicians in non-surgical fields (such as internal medicine). Root cause analysis revealed a number of contributing causes, with diagnostic errors and communication errors the primary culprits. Interestingly, the injured patients did not file a malpractice lawsuit in the vast majority of cases. This study confirms and extends prior research showing that many WSPEs actually occur outside the operating room. The authors call for strict adherence to the Joint Commission Universal Protocol in order to prevent these never events.