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Journal Article > Study
Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.
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.
Journal Article > Study
Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.
Neily J, Soncrant C, Mills PD, et al. JAMA Network Open. 2018;1:e185147.
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.
Journal Article > Commentary
Goolsarran N, Martinez J, Garcia C. BMJ Open Qual. 2019;8:e000593.
Near misses can uncover process weaknesses and motivate improvement to prevent similar incidents. This commentary outlines how one hospital used Plan–Do–Study–Act cycles to improve their MRI screening process, including developing and implementing a safety checklist in the electronic medical record and building in a hard stop to prompt checking for contraindications.