U P DAT E S Quarterly Update on Wrong-Site Surgery: Eleven Years of Data Collection and Analysis Theresa V. Arnold, DPM Since July 2004, 646 wrong-site surgery events have been reported through the Manager, Clinical Analysis Pennsylvania Patient Safety Reporting System (PA-PSRS) and analyzed by the Pennsylvania Patient Safety Authority Pennsylvania Patient Safety Authority. Data collected through the fourth quarter of the 2014-2015 academic year marks 11 complete years of review and analysis. As noted in the Figure, steady progress was made in the number of events reported since the 2007-2008 academic year—the year the Authority’s Preventing Wrong-Site Surgery project began. However, throughout the 2014-2015 academic year, consistent regres- sion was noted in the number of quarterly events reported as compared with the two previous years, with the exception of the first quarter. A total number of 58 events were reported in the most recent academic year, reflecting the highest number of events since 2009-2010. Twenty-one events were reported in the last quarter of the 2014-2015 academic year, the highest quarterly number of reported events since the first quarter of the 2008- 2009 academic year (i.e., 27 quarters of data collection). Of the events reported from Pennsylvania operating rooms (ORs) this quarter, 23.8% (n = 5) accounted for wrong- site anesthesia blocks—one of which was administered by an anesthesiologist and the other four by surgeons. The other types of wrong-site surgery events were as follows: wrong-site procedures (23.8%, n = 5), three of which were wrong-site hand procedures involving a trigger finger release; misidentified spinal levels (23.8%, n = 5); wrong-side procedures (14.3%, n = 3); wrong-side ureteral stent placements (9.5%, n = 2); and a wrong-side pain management procedure (4.8%, n = 1). The three most common types of wrong-site OR procedures reported through PA-PSRS since July 2004 continue to persist and account for more than 50% of events: anes- thetic blocks by anesthesiologists and surgeons (27.4%, n= 177 of 646), wrong-level spinal procedures (12.7%, n = 82 of 646), and pain management procedures (11.1%, n = 72 of 646). Figure. Pennsylvania Patient Safety Authority Wrong-Site Surgery Reports by Academic Year NUMBER OF REPORTS Jul to Sep Oct to Dec Jan to Mar Apr to Jun 80 21 60 19 8 16 14 11 9 17 21 16 21 40 11 10 16 18 16 14 19 15 11 17 13 14 17 16 13 10 20 13 11 15 23 23 6 11 15 19 17 MS15434 16 16 16 13 11 10 8 Scan this code 0 with your mobile 5 6 7 8 9 0 1 2 3 4 5 -0 -0 -0 -0 -0 -1 -1 -1 -1 -1 -1 device’s QR reader 04 05 06 07 08 09 10 11 12 13 14 to access the 20 20 20 20 20 20 20 20 20 20 20 Authority's toolkit on this topic. ACADEMIC YEAR Vol. 12, No. 3—September 2015 Pennsylvania Patient Safety Advisory Page 119 ©2015 Pennsylvania Patient Safety Authority U P DAT E S The reason for the observed regression patient was brought to the procedure correct surgical sites were marked is not clearly understood. Familiar mis- room and assisted to the prone with the patient’s approval, and a haps and system failures continue to position on the procedural table. surgical time-out was performed prior occur in all three phases of the Universal The time-out was completed. The to case. The shoulder procedure was Protocol.1 To maximize its effectiveness patient’s procedure started, and the done first. Once completed, the OR and ensure the success of any wrong-site appropriate spinal level was identi- circulator reviewed the procedure and surgery program, it is essential that surgi- fied by fluoroscopy. The patient was site to be done next for the trigger cal teams (1) ensure that all preoperative injected at the appropriate spinal finger release. The surgeon started to documents are verified against the pri- level at the site marking on the left make an incision on the left thumb mary sources and (2) maintain situational side. Immediately following the injec- in error. The circulator stopped the awareness not only during the time-out tion, the patient stated that he felt surgeon as soon as the incision was but also throughout the procedure.2 symptoms from injection on the left made. The incision was closed and An essential step in the preoperative but his pain was on his right side. the correct trigger finger release was verification and reconciliation process The consent was then checked and performed. is confirming that all the patient docu- noted that the patient’s pathology Please visit the Authority’s website for the ments (i.e., OR schedule, consent, and was noted to be on the right side. full suite of wrong-site surgery prevention history and physical) align with the Between 2007 and 2014, the Authority tools at http://patientsafetyauthority.org/ patient’s understanding of the procedure. led three collaboration projects to help EducationalTools/PatientSafetyTools/ The following scenario illustrates the drive change in about 80 healthcare PWSS/Pages/home.aspx. The newest potential outcome when this practice is facilities. Through these collaborations addition to the collection is the Gap overlooked:* and independent requests, the Authority Analysis and Action Plan to Prevent Patient arrived for a right transfo- has performed on-site consultations and Wrong-Site Surgery tool. This tool pro- raminal epidural steroid injection. observations of Pennsylvania ORs. Failure vides surgical teams with the opportunity Patient was asked where he was to visualize and reference the site mark in to identify potential practice gaps as com- having pain. The patient used his the prepped and draped field is a consis- pared with the 21 evidenced-based best left arm and pointed to the location tently observed deficiency that is relayed practices issued by the Authority.3 on the patient's back. The physician during team debriefing sessions. The To request additional information about then marked the patient’s back. The following report is an example of such the Authority’s Preventing Wrong-Site an observation: Surgery program, including an on-site Patient was having a left shoulder consultation, Pennsylvania hospitals and * The details of the PA-PSRS event narratives arthroscopy and a trigger finger ambulatory surgical centers may contact in this article have been modified to preserve release of the left ring finger. The their patient safety liaison. confidentiality. NOTES 1. Joint Commission. The Universal 2. Clarke JR. Wrong surgery: why does not correct-site surgery [online]. 2012 Dec Protocol for preventing wrong site, the Universal Protocol solve the problem? [cited 2015 Jul 21]. http://patientsafety wrong procedure, and wrong person Am J Surg 2015 Jul;210(1):14. authority.org/EducationalTools/Patient surgery [poster online]. [cited 2015 Jul 3. Pennsylvania Patient Safety Authority. SafetyTools/PWSS/Pages/principles.aspx 21]. http://www.jointcommission.org/ Principles for reliable performance of assets/1/18/UP_Poster1.PDF Page 120 Pennsylvania Patient Safety Advisory Vol. 12, No. 3—September 2015 ©2015 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 12, No. 3—September 2015. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2015 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (MCARE) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. 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