Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: Are they preventable?

Area of Science:

• Patient Safety
• Medical Error Analysis
• Healthcare Quality Improvement

Background:

• Wrong-side/wrong-site, wrong-procedure, and wrong-patient events (WSPEs) are severe adverse events with unknown frequency and root causes.
• Current prevention practices for WSPEs appear inadequate, despite their devastating impact and potential for litigation.

Purpose of the Study:

• To determine the frequency and identify common causes of wrong-side/wrong-site, wrong-procedure, and wrong-patient events (WSPEs).
• To highlight the inadequacy of current prevention strategies and advocate for improved safety measures.

Main Methods:

• Analysis of multiple databases including the National Practitioner Data Bank (NPDB), Florida Code 15 reporting system, ASA Closed Claims Project, and a novel web-based WSPE collection system.
• Estimation of annual WSPE occurrence in the United States based on collected data.

Main Results:

• The NPDB recorded 5940 WSPEs over 13 years; Florida Code 15 reported 494 cases since 1991. An estimated 1300 to 2700 WSPEs occur annually in the US.
• WSPEs occur across all surgical specialties, with high incidence in orthopedic and dental surgery.
• Reporting of WSPEs is minimal in medical literature, contrasting with lay press coverage; common causes and systemic failures were identified.

Conclusions:

• Wrong-side/wrong-site, wrong-procedure, and wrong-patient events are more frequent than appreciated by healthcare providers and patients.
• Preventing WSPEs necessitates innovative technologies, mandatory reporting, and learning from safety initiatives in other high-risk fields.
• Reducing the stigma associated with WSPEs is essential for encouraging reporting and facilitating learning from these adverse events.