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Related Experiment Videos

Righting wrong site surgery.

Pascale Carayon1, Kara Schultz, Ann Schoofs Hundt

  • 1Center for Quality and Productivity Improvement, University of Wisconsin-Madison, USA. carayon@engr.wisc.edu

Joint Commission Journal on Quality and Safety
|July 29, 2004
PubMed
Summary

Preventing wrong site surgery requires understanding system breakdowns. A human factors analysis of surgical care processes can identify communication failures during care transitions, crucial for improving patient safety.

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Area of Science:

  • Patient safety research
  • Human factors engineering
  • Healthcare systems analysis

Background:

  • Wrong site surgery, including wrong side, wrong procedure, and wrong patient, remains a concern despite existing guidelines.
  • Barriers to the effectiveness of current preventative measures for wrong site surgery have been identified.

Observation:

  • A human factors systems analysis can elucidate how work system elements interact to cause breakdowns.
  • A case study in an outpatient setting demonstrates how various work system elements contribute to wrong site surgery.
  • Transitions of care are critical points where communication and information transfer deficits can lead to patient safety issues.

Findings:

  • Deficits in communication and information transfer during care transitions can manifest as miscommunication, delayed information, incorrect information, or misunderstood information.

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  • Analyzing the surgical care process through a work system lens reveals contributing factors to wrong site surgery.

    • Implications:

    • Conducting root cause analyses using a work system model after wrong site surgery is recommended.
    • Collaboration with human factors engineers is advised to effectively apply the work system model for process analysis.
    • Optimizing work systems is essential for reducing the occurrence of wrong site surgery.