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- Communication Improvement
- Education and Training
- Error Reporting and Analysis 4
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Quality Improvement Strategies 5
- Specialization of Care 1
- Teamwork 1
- Identification Errors 5
- Medical Complications 1
- Surgical Complications
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Cases & Commentaries
- Web M&M
Richard A. Smith, DDS; July-August 2007
A patient underwent tooth extraction, but awoke from anesthesia and found that the wrong two teeth had been removed.
Journal Article > Study
Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.
This AHRQ-supported study analyzed information from nearly 3 million operations between 1985 and 2004, discovering a rate of 1 in 112,994 cases of wrong-site surgery. Investigators further evaluated cases with available medical records, all of which were among the malpractice claims. In doing so, they noted that the Joint Commission's Universal Protocol might have prevented only 62% of the cases reviewed. At the rates reported, the authors suggest that the average large hospital may be involved in such an event every 5 to 10 years, a rate 10 times less frequent than retained foreign bodies. They also point out that while wrong-site surgery is a devastating and unacceptable outcome, current efforts to implement protocols may not prevent every event and may, in turn, create inefficiency in related processes. The authors offer a series of recommendations for a model site-verification protocol. The American College of Surgeons offers a fact sheet on correct-site surgery geared toward patient education.
Lee JS, Curley AW, Smith RA. J Oral Maxillofac Surg. 2007;65:1793-1799.
This article discusses strategies to prevent wrong-site tooth extraction including education, improving referral forms, and standardizing preoperative procedures. A prior AHRQ WebM&M commentary also discussed this topic.
ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
This report describes strategies for health care institutions to prevent never events, based on results of a 2008 survey of quality professionals.
Journal Article > Study
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
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.
Altman LK. New York Times. December 11, 2001;1:1.
This news piece reports on wrong-site and wrong-patient surgery and describes efforts to prevent surgical errors following a Joint Commission sentinel event alert on the topic.