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Getting surgery right
John R Clarke1, Janet Johnston, Edward D Finley
1Department of Surgery, Drexel University, Philadelphia, Pennsylvania, USA. jclarke@ecri.org
Objective:
We sought to identify factors contributing to wrong-site surgery (wrong patient, procedure, side, or part).
Methods:
We examined all reports from all hospitals and ambulatory surgical centers--in a state that requires reporting of wrong-site surgery--from the initiation of the reporting requirement in June 2004 through December 2006.
Results:
Over 30 months, there were 427 reports of near misses (253) or surgical interventions started (174) involving the wrong patient (34), wrong procedure (39), wrong side (298), and/or wrong part (60); 83 patients had incorrect procedures done to completion. Procedures on the lower extremities were the most common (30%). Common contributions to errors resulting in the initiation of wrong-site surgery involved patient positioning (20) and anesthesia interventions (29) before any planned time-out process, not verifying consents (22) or site markings (16), and not doing a proper time-out process (17). Actions involving operating surgeons contributed to 92. Common sources of successful recovery to prevent wrong-site surgery were patients (57), circulating nurses (30), and verifying consents (43). Interestingly, 31 formal time-out processes were unsuccessful in preventing "wrong" surgery.
Conclusions:
Wrong-site surgery continues to occur regularly, especially wrong-side surgery, even with formal site verification. Many errors occur before the time-out; some persist despite the verification protocol. Patients and nurses are the surgeons' best allies. Verification, starting with verification of the consent, needs to occur at multiple points before the incision.
Insights
Wrong-site surgery, including wrong-side procedures, remains a concern. Many errors occur before surgical time-outs, highlighting the need for multiple verification points, with patients and nurses as key allies.
Area of Science:
- Patient Safety
- Surgical Error Analysis
- Healthcare Quality Improvement
Background:
- Wrong-site surgery (WSS) is a preventable patient safety event.
- Despite established protocols, WSS continues to occur, necessitating further investigation into contributing factors.
Purpose of the Study:
- To identify factors contributing to wrong-site surgery (wrong patient, procedure, side, or part).
Main Methods:
- Analysis of all reported WSS events (near misses and completed surgeries) in a state requiring mandatory reporting.
- Data collected from June 2004 to December 2006.
Main Results:
- 427 WSS reports over 30 months, with wrong-side surgery being most frequent (298).
- Common error contributors included patient positioning, anesthesia interventions before time-out, and inadequate consent/site verification.
- Patients (57) and circulating nurses (30) were crucial in preventing errors, while 31 formal time-outs failed to prevent WSS.
Conclusions:
- WSS, particularly wrong-side procedures, persists despite formal verification processes.
- Errors frequently occur pre-operatively and can bypass time-out protocols.
- Multi-point verification, involving patients and nurses, is essential before surgical incision.
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