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[Wrong-site surgery: incidence and prevention].

Brian Bjørn¹, Louise Isager Rabøl, Elisabeth Brøgger Jensen

¹H:S Direktionen, H:S Enhed for Patientsikkerhed, H:S Hvidovre Hospital, Afsnit 023, Hvidovre.

Ugeskrift for Laeger

|December 7, 2006

Summary

Implementing "The Five Steps" in the Copenhagen Hospital Corporation (H:S) reduced wrong-site surgery incidents. This patient safety initiative emphasizes structured communication and identification, requiring a cultural shift rather than significant investment.

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Area of Science:

Healthcare Management
Patient Safety
Surgical Quality Improvement

Context:

Wrong-site surgery is a rare but serious adverse event.
Root cause analyses of incidents in the Copenhagen Hospital Corporation (H:S) revealed systemic issues.

Purpose:

To describe the implementation of a method to prevent wrong-site surgery.
To illustrate how adverse event reporting can drive organizational change.

Summary:

A method to prevent wrong-site surgery, adapted from the U.S. Department of Veterans Affairs and known as "The Five Steps," was implemented in H:S.
The method enhances patient identification and team communication, addressing key findings from root cause analyses.
Incident reports indicated a need for a more structured approach to pre-surgical identification and communication.

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Impact:

The Five Steps are a low-resource, culture-focused intervention applicable across Danish hospitals.
Successful implementation demonstrates a model for using adverse event data to improve patient safety protocols.
This initiative highlights the critical role of systematized processes and team communication in preventing surgical errors.