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Related Experiment Videos

Getting surgery right.

John R Clarke1, Janet Johnston, Edward D Finley

  • 1Department of Surgery, Drexel University, Philadelphia, Pennsylvania, USA. jclarke@ecri.org

Annals of Surgery
|August 25, 2007
PubMed
Summary
This summary is machine-generated.

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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.

Related Experiment Videos

  • 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.