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Search results for "Wrong-Site Surgery"

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  • Wrong-Site Surgery
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Patient Safety Primers

Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery

Few medical errors are as terrifying as those that involve patients who have undergone surgery on the wrong body part, undergone the incorrect procedure, or had a procedure intended for another patient. These "wrong-site, wrong-procedure, wrong-patient errors" (WSPEs) are rightly termed never events.

Journal Article > Review

Wrong-site nerve blocks: a systematic literature review to guide principles for prevention.

Deutsch ES, Yonash RA, Martin DE, Atkins JH, Arnold TV, Hunt CM. J Clin Anesth. 2018;46:101-111.

Wrong-site procedures are considered never events, yet they continue to occur. This review describes the incidence, impacts, and contributing factors of wrong-site nerve blocks. The authors recommend verifying the procedure and patient with multiple sources of information, using visible site markings, and employing time outs immediately prior to anesthetic use. A WebM&M commentary discussed an incident involving a wrong-site nerve block.

Book/Report

Adverse Health Events in Minnesota: 14th Annual Public Report.

St. Paul, MN: Minnesota Department of Health; February 2018.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2017 report summarizes information about 341 adverse events that were reported and found that the number of fall-related deaths and wrong-site surgeries increased, while incidents of pressure ulcers decreased. Reports from previous years are also available.

Journal Article > Commentary

A surgical procedure grid for safety and operating room communication in multisite surgery.

Insalaco LF, Spiegel JH. JAMA Facial Plast Surg. 2018;20:185-186.

Wrong-patient and wrong-site surgeries are considered never events. This commentary describes a tool developed to decrease confusion in plastic surgery. The authors envision the tool to enhance team communication and preparation, which should reduce risk of wrong-site surgery.

Journal Article > Commentary

Wrong-site surgery.

Engelhardt KE, Barnard C, Bilimoria KY. JAMA. 2017;318:2033-2034.

This commentary describes a case of wrong-site surgery, an erroneous breast biopsy, and the resulting disclosure of the error and investigation. Root cause analysis uncovered multiple process vulnerabilities. The authors suggest that errors provide opportunities to design system solutions to prevent errors.

Journal Article > Study

Preoperative site marking: are we adhering to good surgical practice?

Bathla S, Chadwick M, Nevins EJ, Seward J. J Patient Saf. 2017 Jun 29; [Epub ahead of print].

Wrong-site surgery represents a never event. In the United States, The Joint Commission requires marking of the surgical site prior to surgery as part of the Universal Protocol. Researchers conducted a survey study of 120 surgeons in the United Kingdom and found significant variation in adherence to the national mandate for preoperative surgical site-marking.

Journal Article > Review

High reliability of care in orthopedic surgery: are we there yet?

Anoushiravani AA, Sayeed Z, El-Othmani MM, Wong PK, Saleh KJ. Orthop Clin North Am. 2016;47:689-695.

High reliability organizations have developed methods for achieving safety despite hazardous conditions. This review explores the importance of establishing a culture of safety and leadership commitment to achieve high reliability in health care. The authors discuss the benefits of applying high reliability principles in orthopedic practice to standardize approaches and prevent wrong-site surgery.

Journal Article > Commentary

Effectiveness of surgical safety checklists in improving patient safety.

Ragusa PS, Bitterman A, Auerbach B, Healy WA III. Orthopedics. 2016;39:e307-310.

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.

Journal Article > Commentary

Wrong site surgery: a critical incident analysis of a near miss.

Tichanow S. J Perioper Pract. 2016;26:11-15.

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.

Journal Article > Review

Patient safety in dermatologic surgery part 1. Patient safety in procedural dermatology part 2.

Lolis M, Dunbar SW, Goldberg DJ, Hansen TJ, MacFarlane DF. J Am Acad Dermatol. 2015;73:1-26.

This two-part review series explores patient safety in dermatologic practice. The first article discusses safety issues and error reduction tactics in dermatologic surgical practice, highlighting the importance of correct site identification. The second review examines safety problems associated with cosmetic procedures, including complications around nonphysician operators in this field.

Journal Article > Study

Biopsy site selfies—a quality improvement pilot study to assist with correct surgical site identification.

Nijhawan RI, Lee EH, Nehal KS. Dermatol Surg. 2015;41:499-504.

This study found that encouraging patients to take skin biopsy selfies on smartphones may help patients and physicians more accurately identify the correct biopsy site for subsequent surgical excision, potentially avoiding wrong-site surgeries.

Journal Article > Study

'Sorry, I meant the patient's left side': impact of distraction on left-right discrimination.

McKinley J, Dempster M, Gormley GJ. Med Educ. 2015;49:427-435.

Wrong-side procedures still occur at alarming rates, particularly outside of the operating room. This study exposed medical students to various types of distractions and measured their ability to distinguish a person's left from right side from different perspectives. Cognitive distractions had a bigger negative impact than ambient ward noise on the students' performance.

Cases & Commentaries

Two Wrongs Don't Make a Right (Kidney)

  • Spotlight Case
  • Web M&M

by John G. DeVine, MD; March 2015

A man with suspected renal cell carcinoma seen on CT in the right kidney was transferred to another hospital for surgical management. The imaging was not sent with him, but hospital records, which incorrectly documented the tumor as being on the left side—were. The second hospital did not obtain repeat imaging, and the surgeon did not see the original CT prior to removing the wrong kidney.

Journal Article > Review

Applying fault tree analysis to the prevention of wrong-site surgery.

Abecassis ZA, McElroy LM, Patel RM, Khorzad R, Carroll C IV, Mehrotra S. J Surg Res. 2015;193:88-94.

This systematic review investigated root causes of wrong-site surgery and identified three vulnerabilities: transcription errors prior to surgery, intraoperative verification failures, and omitting steps in the verification process. The Universal Protocol does not mitigate these vulnerabilities, suggesting that further interventions are required to prevent wrong-site surgeries. A recent AHRQ WebM&M commentary provides an overview of wrong-site surgery and best practices to prevent it.

Web Resource > Multi-use Website

Joint Commission Center for Transforming Healthcare.

The Joint Commission.

The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality improvement (QI) in areas related to its accreditation functions. In the first major initiative under the leadership of new president Dr. Mark Chassin, The Joint Commission launched this Center, which will focus on applying rigorous QI methods to improve safety in a number of challenging areas (the first three are hand hygiene, handoff communication, and preventing wrong site surgery) and disseminating the lessons from these efforts. This Web site provides more information about the Center and its goals.

Cases & Commentaries

Turn the Other Cheek

  • Web M&M

John Starling III, MD; March 2012

Following biopsies for two skin lesions on his left cheek, a patient was sent to an outside surgeon for excision of squamous cell carcinoma. Although the referral included a description and diagram, the wrong lesion was removed.

Journal Article > Study

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

After several episodes of incorrect surgical procedures, a medical center conducted individual root cause analyses and summarized the findings to identify common causes of each individual error. These findings were used to implement systematic prevention measures.

Journal Article > Study

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.

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.

Journal Article > Study

Outcome of 6 years of protocol use for preventing wrong site office surgery.

Starling J 3rd, Coldiron BM. J Am Acad Dermatol. 2011;65:807-810.

This study describes the use of a tool to prevent wrong site procedures in a dermatologic surgery setting.

Newspaper/Magazine Article

The pain of wrong site surgery.

Boodman SG. Washington Post. June 21, 2011:E1.

This newspaper article reports on a case of wrong-site surgery and explores initiatives to prevent such errors, including the Universal Protocol and Partnership for Patients program.

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